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Available Forms

New Patient Questionnaire - Kara Wallace, MD

Our office is currently accepting new patients. Primarily your visits will be with our Certified Nurse Practitioner. Before submitting this form please determine if this is acceptable to you. Please note that not all insurance carriers cover nurse practitioners. Anna Adams, CRNP, has been a great asset to our practice and continues to provide our patients with excellent care. Courtenay Simmons, CRNP has been treating patients in the Tennessee Valley for several years and we are very glad that she joined us in providing excellent care to the patients of our practice.

Who is the insured policyholder employed by?
What is the name of your Insurance Carrier?

Please note we are not accepting New patients with United HealthCare, Humana, Medicare Replacement plans and a few others. If you are unsure if we are accepting new patients with your insurance please call our office.
Please provide the amount of your co-payment or co-insurance per your insurance carrier. If you are unsure of this amount please contact your insurance carrier for assistance.
Deductible amount per your Insurance Carrier. If you are unsure of this amount please contact your Insurance Carrier for assistance. If there is no deductible please state "none".

Chronic/Ongoing Health Issues

Please list all chronic health issues which you are treated for. If none, please state "none".
 
 
Please list all current prescription and over the counter medications you are taking. If none please state "none".

Medications and Controlled Substances

At this time, our Nurse Practitioner is not able to prescribe controlled substances. Please advise us if you are prescribed medication(s) which may fall under the categories listed below.

Are you currently taking any sleep-aid medication(s)? If yes, please note we will not be able to prescribe these medications for you.
If currently on pain medication, please note we will not be able to prescribe these medications for you.

Be advised - We are not a pain management clinic / facility.

 
Are you currently taking any anti-depressant(s) or anti-psychotic medication(s)?
If no, please indicate none.

If yes, please indicate if is this being managed by another practitioner or clinic?
Are you currently taking any anti-anxiety medication(s)? If yes, please note we will not be able to prescribe these medications for you if they are a controlled substance.
 
Are you currently taking any ADD or ADHD Medication(s)? If yes, please note we will not be able to prescribe these medications to you.
 
Who was your previous Family Doctor?
What type of problem would you like to schedule an appointment for? How soon would you like to schedule and appointment for if you are accepted as a new patient?
 
How did you learn about our practice?
What is your email address so that we may contact you through our secure portal?

One of our staff members will contact you with an appointment date and time if we are able to provide services to you.

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