Patient’s Name*

Date of Birth - MM/DD/YEAR*

Phone*

Email*

Best Time to Call
---MorningAfternoonEveningNo Preference

Desired Appointment Day
---MondayTuesdayWednesdayThursdayFridayNo Preference

Desired Appointment Time
---morningafternoon

Desired Appointment Location*
---Dowell Springs OfficeFarragut OfficePowell OfficeUT Medicial Center Office

Desired Appointment Provider*
---Edward J. Primka, III, M.D.Drew W. Miller, M.D.Elizabeth Ergen, M.D.Misty Hammond, DNPMelissa Headrick, NP-CSandra L. Vaughn, NP-CKevin Blazer, PA-CCameron Stengel, PA-CBlake Childress, PA-CLauren Church, PA-CSharon McNutt, PA-CMarcus Ortiz, PA-CJennifer Webster, PA-C
*Note not all providers work at each location.

Brief Description of the Nature of Your Visit*