1404 Tusculum Blvd., MOB 3, Suite 3000, Greeneville, TN 37745

Mon - Fri, 7:40am - 4:30pm

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Patient Registration

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Become a New Patient

Becoming a patient at Greeneville Family Medicine is easy…we will guide you through every step of the process.

Here are few of the insurances we take.

To get started, we just need some basic information. Please complete and submit the form below.

1Step

2Step

3Step

First Name:
Last Name:
Email:
Phone:
Date of Birth:
MM slash DD slash YYYY
Upload Photo of Insurance Card
Accepted file types: jpg, png, pdf, Max. file size: 15 MB.
Message

SUMMIT MEDICAL GROUP PAITENT REGISTRATION FORM
ACCOUNT
DATE
MM slash DD slash YYYY
PHYSICIANS NAME
PATIENT'S NAME
First Middle Last
BIRTH DATE
MM slash DD slash YYYY
AGE
ADDRESS
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
SOCIAL SECURITY
HOME PHONE
MOBILE PHONE
WORK OR BUSINESS PHONE
MARITAL STATUS
SEX
EMPLOYER'S NAME AND ADDRESS
RACE
- AFRICAN AMERICAN
- ASIAN
- CAUCASIAN
- HISPANIC
- NATIVE AMERICAN
EMAIL ADDRESS
PRIMARY LANGUAGE
PHARMACY OF CHOICE
PHARMACY PHONE
HOW WERE YOU REFERRED TO SUMMIT MEDICAL GROUP ?
HAVE YOU BEEN TREATED BY A SUMMIT MEDICAL GROUP PHYSICIAN PREVIOUSLY?
- YES
- NO
DO YOU HAVE A DURABLE POWER OF ATTORNEY FOR HEALTHCARE?
- YES
- NO
DO YOU HAVE A LIVING WILL?
- YES
- NO
If yes, please provide a copy of the above documents(s) to the office for your medical record.
PERSON/GUARANTOR RESPONSIBLE FOR PAYMENT OF SERVICES (IF DIFFERENT FROM PATIENT)
NAME
First Middle Last
RELATIONSHIP TO PATIENT
ADDRESS
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
SOCIAL SECURITY
HOME PHONE
MOBILE PHONE
WORK OR BUSINESS PHONE
BIRTH DATE
MM slash DD slash YYYY
SEX
EMPLOYER'S NAME AND ADDRESS
EMERGENCY CONTACT (NOT WITHIN THE SAME HOUSEHOLD)
NAME
EMERGENCY PHONE NUMBER
RELATIONSHIP TO PATIENT
INSURANCE INFORMATION
PRIMARY INSURANCE
INSURANCE NAME
EFFECTIVE DATE
MM slash DD slash YYYY
CLAIMS ADDRESS
SUBSCRIBER ID NUMBER
GROUP NUMBER
SUBSCRIBER NAME AND ADDRESS
SUBSCRIBER BIRTHDATE
MM slash DD slash YYYY
SUBSCRIBER SS
RELATION TO PATIENT
EMPLOYER NAME, ADDRESS AND PHONE NUMBER
SECONDARY INSURANCE
INSURANCE NAME
EFFECTIVE DATE
MM slash DD slash YYYY
CLAIMS ADDRESS
SUBSCRIBER ID NUMBER
GROUP NUMBER
SUBSCRIBER NAME AND ADDRESS
SUBSCRIBER BIRTHDATE
MM slash DD slash YYYY
SUBSCRIBER SS
RELATION TO PATIENT
EMPLOYER NAME, ADDRESS AND PHONE NUMBER
FOR PRESCRIPTIONS, DO YOU USE YOUR
- PRIMARY INSURANCE
- SECONDARY INSURANCE
The Patient or Guarantor is responsible for payment in full of all services rendered by the physicians or employees of Summit Medical Group, PLLC. Payment in full is expected at the time of service unless arrangements are made in advance.
AUTHORIZATION, ASSIGNMENT, AND RESPONSIBILITY OF ACCOUNT
I thereby authorize Summit Medical Group, PLLC to release to the above insurance companies &/or carriers any medical or other information needed for claims reimbursement.
I hereby assign, transfer, and set over to Summit Medical Group, PLLC all of my rights, title, and interest to medical reimbursement benefits under my insurance policy with the above documented insurance companies. I hereby acknowledge and accept responsibility for payment in full of all services rendered to me by Summit Medical Group, PLLC.
DATE
MM slash DD slash YYYY
SIGNATURE OF PATIENT/GUARDIAN
Max. file size: 128 MB.

Greeneville Family Medicine

1404 Tusculum Blvd., Suite 3000
Michael H. Hartsell, M.D., Sonja B. Woods, M.D., Kara Lankford, PA-C, Brian Gong, FNP, Shalee Nanney, FNP
NAME*
TODAY'S DATE*
MM slash DD slash YYYY
Date of Birth*
MM slash DD slash YYYY
Age*
Social Security Number*
CURRENT MEDICAL PROBLEM
* Please list and describe the problem for which you came to see the doctor today.
Description of Problem*
Date Began*
MM slash DD slash YYYY
What concerns you most about this problem or problems ?*
PAST MEDICAL HISTORY
* Please List All Medical Problems.
Medical Problems
For how long ? (years)
Medical Problems
For how long ? (years)
Medical Problems
For how long ? (years)
Medical Problems
For how long ? (years)
Medical Problems
For how long ? (years)
* Please List All Surgeries You Have Had.
Type of Surgery /Procedure
Medical Facility / Hospital
Doctor
City
Type of Surgery /Procedure
Medical Facility / Hospital
Doctor
City
Type of Surgery /Procedure
Medical Facility / Hospital
Doctor
City
Type of Surgery /Procedure
Medical Facility / Hospital
Doctor
City
* Please List All Hospitalizations (fore reasons s other than surgery)
Illness / Problem
Medical Facility / Hospital
Doctor
City
Illness / Problem
Medical Facility / Hospital
Doctor
City
Illness / Problem
Medical Facility / Hospital
Doctor
City
Illness / Problem
Medical Facility / Hospital
Doctor
City
Are you currently under the care of any other practitioner(s)?
- NO
- YES
* If Yes, please describe the illnesses or medical problems for which you are being treated:
Illness or Medical Problem
Practitioner or Facility
City
Illness / Problem
Practitioner or Facility
City
Illness / Problem
Practitioner or Facility
City
Illness / Problem
Practitioner or Facility
City
* For Women only:
How many times have you been pregnant?
How many times have you given birth?
Any miscarriages or abortions?
Do you have regular monthly periods?
- YES
- NO
* Please List all medications you are now taking that a DOCTOR HAS PRESCRIBED
* Please list all medications you use such as aspirin, cold tablets, vitamins, herbs, laxatives, antacids, or any medicine bought WITHOUT A PRESCRIPTION
Name of Medicine, Vitamins etc.
ALLERGIES AND SENSITIVITIES
* Please list all medicines you are allergic to and describe how each one affects you.
Name of Medicine You Are Allergic to
Reaction
Name of Medicine You Are Allergic to
Reaction
* Please list any food, dust, chemical, soap, pollen, household ttem, bee sting, etc., that you are allergic to and describe how each one affects you
Name of Substance You Are Allergic to
Reaction
Name of Substance You Are Allergic to
Reaction
Are you allergic to eggs or egg products?
- YES
- NO
FAMILY HEALTH AND HISTORY
* Please give the following information about your immediate family:
Your Mother Name
Age if Living
Age at Death
State of Health or Cause of Death
Your Father Name
Age if Living
Age at Death
State of Health or Cause of Death
Your Mother's Parents:
Grand Mother Name
Age if Living
Age at Death
State of Health or Cause of Death
Grand Father Name
Age if Living
Age at Death
State of Health or Cause of Death
Your Father's Parents:
Grand Mother Name
Age if Living
Age at Death
State of Health or Cause of Death
Grand Father Name
Age if Living
Age at Death
State of Health or Cause of Death
Your Siblings (Brothers and Sisters) -- Please list all, from oldest to youngest in order
Siblings Name
Age if Living
Age at Death
State of Health or Cause of Death
Siblings Name
Age if Living
Age at Death
State of Health or Cause of Death
Siblings Name
Age if Living
Age at Death
State of Health or Cause of Death
Siblings Name
Age at Death
Age at Death
State of Health or Cause of Death
Your Children (Please list all, from oldest to youngest in order)
Child Name
Age if Living
Age at Death
State of Health or Cause of Death
Child Name
Age if Living
Age at Death
State of Health or Cause of Death
Child Name
Age if Living
Age at Death
State of Health or Cause of Death
Child Name
Age if Living
Age at Death
State of Health or Cause of Death
Please list any BLOOD RELATIVES that have the following illnesses.
ILLNESS
Family Member
(e.g.. "mother", “uncle")
ILLNESS
Family Member
(e.g.. "mother", “uncle")
Stroke
Family Member
Polio
Family Member
SOCIAL HISTORY AND PERSONAL HABITS
* Please list who lives with you at home
* Please give the name of your spouse (and the date of marriage and/or divorce)
* Please list your occupation:
How long?
Church you attend:
* Birth Place
Family Home
* Substance use
Are you currently a smoker?
- YES
- NO
Smoke?
- Cigarettes
- Cigars
- Pipe
Have you smoked in the past?
- YES
- NO
If so, how long?
Do you chew tobacco or dip snuff?
- YES
- NO
If so, how long?
Do you use alcohol-containing beverages?
- YES
- NO
If yes, circle the type
- Beer
- Wine
- Distilled Liquor
And circle how often
- Daily
- Weekly
- Monthly
- Yearly
- Very Rarely
* Education
How far did you go in school?
High school you attended:
Graduated (Year)
If you did not graduate, do you have your G.E.D?.
- YES
- NO
Do you have training in a trade?
- YES
- NO
If yes, please list:
* Do you exercise?
- YES
- NO
If yes, how?
How often?
What do you do for fun?
Have you recently had any changes in any of the following? If yes, please explain?
Marital status?
- YES
- NO
If yes, please explain?
Job or work?
- YES
- NO
If yes, please explain?
Residence?
- YES
- NO
If yes, please explain?
Financial status?
- YES
- NO
If yes, please explain?
Are you having any legal problems or trouble with the law?
- YES
- NO
If yes, please explain?
Have you recently felt unsafe or endangered in your home?
- YES
- NO
If yes, please explain?
HEALTH PRESERVATION
When was your last complete physical exam?
Have you had a tetanus booster in the last 10 years?
- YES
- NO
For Women only:
When was your last Pap smear:
When was your last Mammogram?
Do you wear seatbelts while riding or driving in the car?
- YES
- NO
Do you wear a helmet when riding a bike or motorcycle?
- YES
- NO
Thank you for completing this questionnaire. Your doctor will review this information carefully.
And again, welcome to our practice!

Call 423-638-1188 and press 4 to schedule an appointment today with an Greeneville Family Medicine primary care provider, the first step to a healthier life.

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1404 Tusculum BLVD. MOB 3, Suite 3000 Greeneville, TN 37745

423-638-1188
Mon-Fri, 7:40am-4:30pm

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© 2022 GreenevilleFamilyMedicine. All Rights Reserved.