phone: 828.645.7974
fax: 828.645.9798

104 North Main Street
Weaverville, NC 28787


Forms

New Patient Forms
We are currently not accepting new patients.


Yearly Physical Forms (non-Medicare)
If you are coming in for your yearly physical, please complete the following forms and bring them with you to your appointment:

We realize you may have previously filled out the last 2 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.


Medicare Annual Wellness Exam Forms
If you are coming in for your Welcome to Medicare or Annual Wellness Visit, please complete the following forms and bring them with you to your appointment:


All 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.

Financial Policy
This explains our current financial policies.

HIPAA/Verbal Communication Release Form
This advises us as to who, if anyone, we may speak with about medical or financial matters related to you.

Medical History Questionnaire - Adult (age 18 & over)
For new adult patients or those who want to establish with our office but have not seen a primary care provider in the past two years.

Medical History Questionnaire - Pediatric (age 17 & under)
For new pediatric patients or those who want to establish with our office but have not seen a primary care provider in the past two years.

Patient Privacy Policy
This describes our policies and procedures and your rights regarding your private information.

Patient 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, emergency contact, responsible party and insurance information. Complete this form if you are a new patient or if you have changed your address, phone number(s), employment, marital status, or emergency contact.

Medical History Update - Adult
For established adult patients who are coming in for their yearly physical. Please complete this form and bring it to your appointment.


Forms for School

North Carolina School Sports Physical Form
For students wishing to participate in athletics.

Kindergarten Physical Form
North Carolina health assessment form for those entering kindergarten. Parents - please complete the parent section prior to your child's appointment with us.


Advanced Directives

North Carolina Advance Healthcare Directive Registry
For Living Will, Organ Donor Card, Healthcare Power of Attorney forms (click on the Forms link)


License and Handicap Placard Forms and Applications

DOT 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.

North Carolina Handicap Placard Applications
Applications if you need to apply for a temporary or permanent handicap placard, or a handicap driver's registration plate.