Dr. Michael W. Goodman & Dr. Matthew E. Bagamery

Downloadable Patient Forms

We have six patient forms that you need to complete before seeing one of our physicians. By completing these forms before your first visit, it will save us time in setting up your patient file — and reduce the amount of time you spend in our waiting room. In order to open these files, you will need Adobe Acrobat Reader, which can be downloaded at no charge by clicking here.

There are two ways to open the forms:
(1) Open a form from this web site. Click on one of the following links to open a form online. You can then print the form from your browser window. Please note: These forms may take a few minutes to open. If you are using a dial-up (modem) Internet connection, we recommend that you download the forms (see option #2) or open each form individually. If you have high-speed Internet access, we suggest that you choose the Full New Patient Packet, which includes all six forms.

OR

(2) Download the forms to your computer.
If you are using a PC: Right click on the name of a form and choose "Save As". If you are using a Mac: Click and hold over the name of a form. A dialogue box will appear, prompting you to "Save file as..." For both PC and Mac: - Select the destination on your computer where you would like to save the file and click "Save." - The file will be saved to your computer. You can then open and print the form at any time.

Full New Patient Packet
(includes all of the below forms)

Please print and complete these forms and bring them with you to your appointment. Also, please bring with you a valid photo ID (such as a driver's license or passport) and your current insurance card.

Insurance Information

Patient Medical Assessment

Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Authorization for Use and Disclosure of Protected Health Information

Erlanger Medical Mall
979 East Third Street
Suite C-0630
Chattanooga, TN 37403
423.267.5677