pencil erasersClick on the link(s) below to print the appropriate form(s).  Complete the form(s), bring them to your appointment, and give them to the receptionist when you check in.

Please be aware that you may be asked to complete additional forms at the time of check-in.

 

NEW PATIENT FORMS FOR PRE-EMPLOYMENT — 3 Pgs

For All New Patients regardless of other services.

Includes:

  • Patient Information
  • Medical History
  • Privacy Notice

DOT PHYSICAL – FORM 649-F (6045) — 3 Pgs

For new DOT drivers and for current drivers needing recertification.
For those who need a Department of Transportation Physical Exam and related services.highway free

Includes:

  • Driver’s Information
  • Health History

EPWORTH SLEEPINESS SCALE — 2 Pgs

For new DOT drivers and for current drivers needing recertification.
For those who need a Department of Transportation Physical Exam and related services.

Includes:WIRC Knox Clinic Hall

  • Questionnaire for Sleep Apnea risk

RESPIRATOR QUESTIONNAIRE — 5 Pgs

For patients needing Respirator Physicals.
For anyone who has been selected to use any type of respirator.

Includes:

  • Questionnaire on respirator usage

AUDIO CONSENT FORM — 2 PgsIWIRC Knox Audio

For patients needing an Audiogram.

Includes:

  • Consent for Testing and Release of Information
  • Questionnaire on Hearing Protection

NEW PATIENT FORMS FOR WORK INJURY CARE — 4 Pgs

For all New Injury Patients.
For any new patient with a work-related injury.

Includes:doctor

  • Patient Information
  • Medical History
  • Privacy Notice
  • Release of Information

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