Patient Forms

NEW PATIENT FORMS

PERSONS AUTHORIZED TO SEEK TREATMENT

GENERAL CONSENT FOR TREATMENT

PATIENT HISTORY FORM

Privacy Information & Forms

PATIENT NOTICE/PRIVACY POLICY

ACKNOWLEDGEMENT OF RECEIPT OF PATIENT NOTICE /PRIVACY POLICY FORM

Medical Records and Patient Information Forms

MEDICAL RECORDS RELEASE FORM - SENDING FROM CMG

MEDICAL RECORDS RELEASE FORM - SENDING TO CMG

Medication Dosing Chart

ACETAMINOPHEN

IBUPROFEN

Dyphenhydramine (Benadryl)

Vaccination/ Immunization Schedules

CHILDHOOD SCHEDULE (BIRTH - 6 YEARS)

ADOLESCENT SCHEDULE (7 - 18 YEARS)

CATCH-UP SCHEDULE (4 MONTHS - 18 YEARS)

Vaccination/ Immunization Information Sheets

CHICKENPOX (VARICELLA)

DIPHTHERIA TETANUS & PERTUSSIS (DTaP)

HAEMOPHILUS INFLUENZAE TYPE B (Hib)

HEPATITIS A (HepA)

Hepatitis B (Hep B)

Human Papillomavirus (HPV)

Influenza (Flu Shot)

Influenza (Flu Mist)

Measles Mumps & Rubella (MMR)

Measles, Mumps, Rubella, and Varicella (MMRV)

Meningococcal ACWY Vaccine (MenACWY and MPSV4)

Serogroup B Meningococcal Vaccine (MenB)

Pneumococcal Congugate Vaccine (PCV13)

Polio (IPV)

Rotavirus (RV)

Tetanus, Diphtheria & Pertussis (Tdap)

Ages & Stages Information Sheets

First Month

2-4 Month

4-6 Month

6-9 Month

9-12 Month

1-2 Years

Toddler years

Adolescent Years

Child Safety Information

Payment Disclosure Form

Car Seat Safety Guide

Internet Policy

OFFICE HOURS

Monday through Friday
8:00 am to 5:00 pm
 

JACKSON AFTER-HOURS CLINIC

Sick Appointments Only
Weekday evenings until 6:30 pm
Saturday and Sunday - 8:00 am to 5:00 pm

Clinton

539-C Highway 80 West

Clinton, MS 39056

Phone: (601) 362-8776

Jackson

1867 Crane Ridge Drive

Suite 101B

Jackson, MS 39216

Phone: (601) 362-8776

Madison

7726 Old Canton Road

Madison, MS 39110

Phone: (601) 362-8776