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931 553.6666


If this is an emergency - Dial 911
Office Hours:

8:00a.m. - 5:00p.m.(Mon-Fri)
8:00a.m. - 12:00p.m.(Sat)
Closed 12:30 - 1:30p.m.
for lunch (Mon-Fri)

Rainbow Kids Clinic Forms

Download, print and fill out the following forms to save you time on your appointment. These will allow the doctor to see your child more quickly during your visit. If your child is already a patient, please let us know if any information has changed.

Treatment Authorization

We cannot provide non-emergent care to any patient not accompanied by someone other that their parents or legal guardian. Please provide written documentation of your consent id you cannot be with your child. You may download the form below or write your own consent form. We will assume that you are giving consent to provide any service we deem necessary and discuss any findings or treatment results to all whom you authorize unless you indicate any limitations in your consent letter.

ADHD Assessment

For those who may have concerns that their child may have ADD/ADHD, anxiety, depression or mood disorders, we ask that you fill out an initial questionnaire and one teacher form allow us time to review them. Once parent and teacher form has been completed, please bring by office and we set up appointment as soon as possible.

Asthma Control Test

You may be asked to bring this form to your child’s asthma follow-up appointment. Please print off and complete form as it provides a numerical score to assess asthma control.

Pediatric Symptom Checklist

This form will need to be completed before each well check for children above the age of seven. To cut down on wait time, please have this form completed and bring with you at your child’s next well check.

Postnatal Depression Scale

As you are pregnant or have recently had a baby, we would like to know how you have been feeling. You may be asked to complete this form at your two-week well check, so in order to cut down on wait time please complete and bring to your child’s visit.

Formularios para Nuevos Pacientes

Release of Medical Information/Prescriptions

Notice of Privacy Practice

Vaccine Policy

Notice of Non-Discrimination 

 

111 Otis Smith Drive, Clarksville, Tennessee 37043 ♦ Phone: 931-553-6666 ♦ Fax 931.553.6681 ♦ Email: info@rainbowkidsclinic.com