Patient Portal

List of forms available to download and complete prior to visit.

 

New Patient Forms

New Patient Packet


Demographic Forms

Under 18 years Demographic Form

Over 18 years Demographic Form


General Forms

Medical History

General Consent Form
(under 18 years)

General Consent Form
(over 18 years)

FCTMC Notice of Privacy Practices

Patient Feedback Form

Consent for minor without parent

Download Baby Booklet


Release of Information

Release of Information from FCTMC

Release of Information to FCTMC

18+ Release of Information


Well-Child Forms

Maternal Depression Survey
(Birth-6 months)

M-Chat Survey
(ages 18-27 months)

Mental Health Survey
(ages 12 years and up)

Developmental Screening for Well-Child Visits *
(1 month -5 years)

* Instructions for caregivers:
- Once on the CHADIS webiste, go to the Families and Teens section
- If a new user on CHADIS go to Register and use the invitation code: 7632362700 (our office phone number)
- If a returning user to CHADIS go to Log-in and enter your account information


Asthma Forms
Childhood Asthma Control Test (C-ACT)
(ages 4-11 years)

Asthma Control Test (ACT)
(ages 12 years and up)


ADD/ADHD/Behavioral Visits

Vanderbilt Parent Initial Form

Vanderbilt Parent Follow-up Form

Vanderbilt Teacher Initial Form

Vanderbilt Teacher Follow-up Form

Mental Health Survey


Depression/Anxiety Visits

Mental Health Survey

top


We request 48 hours to complete forms for sports/camp physicals, immunizations and day care.

 




Patient Portal

To receive a receipt, please allow popups on our secure payment page

Patient's full name:

Patient's phone number:
in this format xxx-xxx-xxxx

Patient Account Number
(found on your bill):