Planned Parenthood

Middle & East Tennessee

Medical Forms

In order to save time when you get to our health center, please read the Notice of Health Information Privacy Practices and print and fill out our Medical Forms Package in advance of your appointment.

1. Notice of Health Information Privacy Practices. You do not need to print this document, you are only required to read it. You will be asked to sign a form in the Medical Forms Package acknowledging that you have read it.

2. If you are coming for a Well Woman Exam (a physical, breast exam, pelvic, and possible pap smear), you will need to complete a comprehensive history form. Please print, fill-out as completely as possible, and bring with you to your appointment. Staff will review the forms with you during your appointment.  It is available here en Espanol.

3. For abortion clients, you can fill out this medical history form in advance of your appointment.  It is available here en Espanol. 

4. If you are coming for a Hormonal Contraception without a Physical Exam (H.O.P.E.) visit (birth control visit without an exam), you can complete this form, and bring it to your appointment. It is available here en Espanol.

5. For STI screenings (sexually transmitted infection), please complete this questionaire in advance of your visit.  It is available here en Espanol.

6. If you are coming for an IUC (Intrauterine Contraception) insertion (Mirena, Paragard, or Skyla), you can complete this form, and bring it to your appointment. 

If you made an appointment for a Mirena IUC insertion (the hormonal intrauterine contraception that is good for up to 5 years) or Skyla IUC insertion (the hormonal intrauterine contraception that is good for up to 3 years) and are using insurance this form must be completed to order your device. Once you have completed this form you can fax it to us at (615) 320-5233 or drop it off at the front desk. Once we submit your form it typically takes 1-2 weeks to receive your device and then we will contact you to confirm your appointment.

If you made an appointment for a Paragard IUC insertion (the non-hormonal intrauterine contraception that is good for up to 12 years) and are using insurance this form must be completed to order your device. Once you have completed this form you can fax it to us at (615) 320-5233 or drop it off at the front desk. Once we submit your form it typically takes 1-2 weeks to receive your device and then we will contact you to confirm your appointment.

7. If you are coming for a Nexplanon insertion, you can complete this form, and bring it to your appointment. It is available here en Espanol.

8. Credit Card Authorization Form. Fill out completely and bring with you to your appointment.

Already a Patient at PPMET and want a quicker way to refill your birth control pills, patches, or rings? Simple. Print off this "Mail Request for Birth Control" form, read carefully, fill out and mail to the PPMET Health Center nearest you or call with further questions. These are our locations:

Nashville
412 Dr. D.B. Todd, Jr. Boulevard
Nashville, TN  37203
615-321-7216

Knoxville
710 N. Cherry St.
Knoxville, TN  37914
865-694-7155

Johnson City
409 East Unaka Ave.
Johnson City, TN  37601
423-504-4447

     
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Medical Forms