Patient Forms

Patient Forms

• Patient Profile Form Under 18
  or Patient Profile Form 18+
• Medical Record Release Form
• Medical History Form - New Patients
• Medical History Form - Established Patients
• Practice Policies/Patient Responsibilities
• COVID-19 Vaccine Informed Consent for Children

Request for Medical/Physical Forms Completion

When requesting a form to be completed by JMA, please fill out the "Request for Completion Form" linked below and submit it along with the form you would like us to complete.

• Request for Completion Form

Forms can be submitted via:

• Email: forms@jeffersandmann.com - Please include the patient's name and office location in the subject line.
• Fax: See your office location's fax numbers.
• Mail: See your office location's mailing address.
• In-person drop-off: See list of office locations.

ADHD / ADD Evaluation Forms

• Vanderbilt Parent Informant Form
• Vanderbilt Teacher Informant Form
• Vanderbilt Parent Informant Follow-up Form
• Vanderbilt Teacher Informant Follow-up Form
• Local Licensed Psychologists who evaluate children for ADHD

School Forms

• Johnston County Medical Authorization Form
• Wake County School Medication Form
• Physical/Sports Form (Johnston/Wake County)
• NC Health Assessment Form
• Daycare Form

HIPAA

• HIPAA Notice of Privacy Practices
• HIPAA Acknowledgement Form 
• Adult Provider Options
• Parent Letter - 17 Year HIPAA Transition Out of Care
• HIPAA Transition to Adult Care Guide