Name of Practice Download and fill out patient forms

Hospital Affiliation

Southern Hills Medical Center


AFFORDABLE CARE and YOU

You may qualify for low or no cost Preventive Care Services.

Annual Wellness Visit - Medicare Annual Wellness Visit - Non-Medicare

For more information or to schedule an appointment, contact us at

(615) 834-6166

To schedule an appointment, please call our offices during regular business hours, Monday- Friday from 8:00am – 5:00pm

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Patient Forms


Registration Forms

If you are a new patient, please fill out the following forms and bring them with you for your appointment. If you have any questions about which packet of forms you need, please call us at (615) 834-6166. Please fax the completed forms along with a copy of your insurance card (front and back) to us at (615) 781-9755.

Patient Registration Form

Patient Consent

Patient History

Patient Privacy Information and Authorization Forms

Authorization for Release of Protected Health Information (PHI)

Notice of Privacy Practices

Aviso Sobre Las Practicas De Privacidad

These forms require Adobe Reader. If you do not have Adobe Reader, you may download it free here: Get Adobe Acrobat Reader (this link opens a new browser window).