Physician Forms

COVID-19 FORMS

• Monoclonal Antibody Therapy Request Form
• Lab After Hours Order Form

SPECIALITY FORMS

Diagnostic

• Cardio, Pulmonology, Neurology Services (Form 31938, Rev 1/22)

Infusion

Click Here for Infusion Forms

Lab

• LAB AFTER HOURS ORDER FORM
• Outpatient Lab Orders (Form 31825, Rev 08/19)
• Supply Form (Form 31675, Rev 01/19)

Nephrology

• Pediatric Nephrology and Hypertension Request for Consultation (Form 33265, Rev 10/21)

Nutrition

• Outpatient Nutrition Order (Form 31770, Rev 04/21)

Radiology

• Outpatient Radiology Order (Form 30428, Rev 09/20)
• Outpatient Radiology Orders - Emory Center (Form 32891, Rev 10/20)
• Outpatient Radiology Orders - Sevier Outpatient Center (Form 32934, Rev 12/20)
• MRI Physician Order (Form 30403, Rev 6/22)

Rehabilitation

• Rehabilitation Referral Form (Form 32434, Rev 12/21)
• Motivating Mealtimes Physician Referral (Form 32467, Rev 07/19)

Sleep

• Request for Sleep Consultation (Form 30166, Rev 04/21)
• Sleep Medicine Center Brochure (Form 31742, Rev 11/20)

Specialists - General

• Referral List and Map (Form 31829, Rev 8/22)
• Physiatry Referral Request (Form 31841, Rev 02/17)

Pediatric Surgery

• East Tennessee Pediatric Surgery Group Referral Request (Form 32869, Rev 4/21)
• Preoperative: Surgical Booking Order (Form 31504, Rev 6/20)

MEDICAL DATA

• 2020-2021 Antibiogram

REGIONAL PRACTICE FORMS

• Adult Patient Information Sheet
• Affidavit for Adult: Spanish (Form 31649, Rev 1/17)
• Authorization for Release of Information (Form 30399, Rev 6/18)
• In Loco Parentis Consent to Treat and Affidavit (Forms 31646 and 32188, Rev 6/20 and 8/18)
• Parent/Guardian Consent for Treatment (Form 31647, Rev 5/20)

• Adult Patient Consent for Treatment
  • English (Form 31648, Rev 12/20)
  • Spanish (Form 31666, Rev 1/17)
• Patient Information for Regional Practices:
  • English (Form 31654, Rev 4/20)
  • Spanish (Form 31655, Rev 4/20)
• Privacy Notice:
  • English (Form 31644, Rev 1/20)
  • Spanish (Form 31645, Rev 1/20)
• What Are My Patient Benefits:
  • English (Form 31735, Rev 8/20)
  • Spanish (Form 32855, Rev 9/20)
    
• Vaccine Policy for Practices:
  • English (Form 32257, Rev 9/20)
  • Spanish (Form 32856, Rev 9/20)