New Patient Forms
We are currently not accepting new patients.
Yearly Wellness Forms
If you are coming in for your yearly wellness exam, please download and fill out the applicable form and bring it with you to your appointment:
We realize you may have previously filled out some of these forms,
but ask that you please complete them again so we are certain
we have the most up-to-date information on file. Thank you.
Other Dry Ridge Family Medicine Forms
Authorization for Release of Medical Records TO Dry Ridge Family Medicine
Complete this form if you want a previous or current provider to send copies of your medical records to Dry Ridge Family Medicine. This gives them permission to do so.
Authorization for Release of Medical Records FROM Dry Ridge Family Medicine
Complete this form if you want us to send copies of your medical records to another provider or person. This gives us permission to do so.
Medical History Questionnaire
Adult (ages 18 & over)
Pediatric (ages 17 & under)
This describes our policies and procedures and your rights
regarding your private information.
Privacy Notice Acknowledgment
Acknowledges that you have been provided with a copy of our Patient Privacy Notice (above).
Patient Registration Information
This form provider us with basic information about you, including date of birth, address, phone numbers, and insurance information.
Complete this form if you have changed your address, phone number(s), employment, marital status, or emergency contact.
Verbal Communication Form
This advises us as to who, if anyone, we may speak with about medical or financial matters related to you.
Forms for School
North Carolina School
Sports Physical Form
For students wishing to participate
Advance Healthcare Directive
For Living Will, Organ
Donor Card, Healthcare Power
of Attorney forms (click
on the Forms link)
License and Handicap Placard Forms
CDL Medical Examiner's Report (Form MCSA-5875)
DOT Medical Examiner's Certificate (Form MCSA-5876)
If you need to schedule a physical for your Commercial Driver's License, please download these forms and complete the Driver's Information section prior to your appointment.
Carolina Application for Handicapped Drivers Registration Plate (Form MVR-37_
North Carolina Application & Renewal of Disability Parking Placard (Form MVR-37A)
Applications if you need to apply for a temporary or permanent handicap placard, or a handicap driver's registration plate.