Prior to being seen, ALL THREE (or four if using a credit card) of the following must be completed:
1) To request an initial evaluation appointment with either Dr. Koch, please complete the online form:
New Patient Referral Form
(Clicking on the link will take you to the online form site)
(Although the online form is preferred, if you do not wish to complete the form online you may download, complete, and return the downloadable form: Referral Form.
Completed forms may be e-mailed to Appointments@DrJackKoch.com or faxed to: (615) 523-1483).
Please complete the following (#’s 2, 3 & 4) AFTER we request it via text:
2) Clinical Information form
Adult Form
Child/Adolescent Form
(Again, the online form is preferred. However, if you would prefer to download, complete, and return the appropriate form prior to your initial evaluation you may do so via the following downloadable forms:
Child & Adolescent Information Form
Adult Information Form
Completed forms may be e-mailed to Appointments@DrJackKoch.com or faxed to: (615) 523-1483).
3) AND, New Patient Agreement:
New Patient Agreement for Dr. Koch
(Once again, the online form is preferred. However, if you would prefer to download, complete, and return the appropriate form prior to your initial evaluation you may do so via the following downloadable forms:
New Patient Agreement for Dr. Koch
Completed forms may be e-mailed to Appointments@DrJackKoch.com or faxed to: (615) 523-1483).
4) AND, please complete either the Credit Card Information form if you would like for us to keep payment information on file (via PCI compliant server):
Credit Card Information Form
