Prior to being seen, ALL THREE of the following must be completed (as well as #4 if you wish to use ACH or Credit Cards for payment):
1) To request an initial evaluation appointment with either Dr. Koch or Vanya Hamrin, please complete the online form:
New Patient Referral Form
(Clicking on the link will take you 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).
2) AFTER you have already been scheduled for an initial evaluation with Dr. Koch or Dr. Hamrin, please be sure to complete the additional information form online:
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, please complete the New Patient Agreement:
New Patient Agreement for Dr. Koch
New Patient Agreement for Dr. Hamrin
(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
New Patient Agreement for Dr. Hamrin
Completed forms may be e-mailed to Appointments@DrJackKoch.com or faxed to: (615) 523-1483).
4) If you wish to use bank-to-bank (ACH - Automated Clearing House) transfers for payment for services, you must complete this form as well:
Consumer ACH Payment Authorization Form (Dr. Koch only)
Downloadable version
OR, if you wish to use a credit card for payment for services, please complete this form:
Consumer Credit Card Payment Authorization Form (Dr. Koch or Dr. Hamrin)
Downloadable version
