Forms & Policies
Prior to your appointment, the forms listed below can be printed for your convenience. Filling them out beforehand will save you time by not having to complete them during your appointment. If you elect not to fill out these forms ahead of time, please arrive 15 minutes prior to your scheduled time.
New Patient Forms
- Demographic Form
- Health History
- General-Agreement-DSP
- Alternate Caregiver Permission Form
- Patient-Payment-Policies-DSP
- Demographic Form for Patients 18 & Up
- Contact Method Update Form
- Service Discount Application
This practice serves all patients, regardless of ability to pay. Discounts for essential services are offered to uninsured or underinsured patients, depending on family size and income (sliding scale discount). Complete the Service Discount Application if you think you may qualify for a sliding fee schedule.
- Sliding Scale Self-Pay Acknowledgment
- Formulario Demográfico Familiar
- Formulario de Actualización de Información de Contacto
- Formulario de Consentimiento e Información Demográfica para Familias Foráneas
Policies
- Notice of Non-Discrimination
- Language Assistance
- HIPAA Notice of Privacy Practices
- Patient Payment Policies
- HIPAA Aviso de Prácticas de Privacidad
- Políticas de Pago Para Pacientes
- Firefly-Advance-Vaccine-Consent
On May 17, 2023, the Governor signed into law HB1380/SB111 (amendment of Tennessee Code Annotated 63.1) stating that only parents or legal guardians of minors can provide consent for vaccination. Firefly Pediatrics is offering an Advance Vaccine Consent form to families. This form, signed by the parent or legal guardian of the patient, will allow us to provide vaccinations when children are brought by stepparents, grandparents, aunts, uncles, or other alternate caregivers.
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