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Registration Forms

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Patient Registration Form - Under 18

Patient Registration Form - 18 and over

Records Release Authorization

Sewanee Pediatrics HIPAA Release Form

Sewanee Pediatrics Medical and Family History Questionnaire

Sewanee Pediatrics Financial Policy Agreement 

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Fillable Forms

Please return completed forms to our secure email.

(Please call us at 931 598-9761 to let us know that you sent your forms.)

Strhssewaneepeds@lpnt.net

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Allergy Injection Consent Form

Asthma Control Test for Children 4 - 11 years old

Asthma Control Test for teens 12 years and older

Boy Scout Camp Form

COVID-19 Vaccine Screening and Consent Form

Food Allergy Emergency Care Plan

Generalized Anxiety Disorder - 7 (GAD-7)

NICHQ Vanderbilt Assessment Scale - PARENT

NICHQ Vanderbilt Assessment Scale - TEACHER

NICHQ Vanderbilt Assessment Follow-up - PARENT

NICHQ Vanderbilt Assessment Follow-up - TEACHER

Pediatric Health Questionnaire for Teens (PHQ-9 Modified for Teens)

Sports Pre-participation History Form - The Athlete with Special Needs 

Sports Pre-participation History Form

School Medication Authorization Form

Screen for Child Anxiety Disorders (SCARED) - Child Version

Screen for Child Anxiety Disorders (SCARED) - Parent Version​​

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Other Clinical Forms

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You can print these forms to complete before

your appointment or complete when you arrive:

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Asthma Management Authorization Form

Seizure Action Plan

TSSAA Return to Play Policy

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