Tom Benton, M.D. Benton Pediatric Group, Inc.











 

Printable Forms

The following forms need to filled out for each patient and given to the office at the first visit:

Patient Information
Insurance Reimbursement
Insurance Assignments and Authorization to Release Information
HIPPA
Newborn History (for Newborns only)
Patient History
Family History
Consent to Medical Information Discussion

Other Printable Forms:

ADD/ADHD
Vanderbilt (new & follow-up)
*Vanderbilt--Parent Follow Up
*Vanderbilt--Teacher Follow Up
*Vanderbilt--Parent New
*Vanderbilt--Teacher New
Consent to Obtain Medical Treatment
Medical Release

 

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