Two locations in Jackson
Bolivar • Brownsville • Dyersburg
Lexington • Huntingdon • Martin • Paris
Ripley • Selmer • Trenton • Union City
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform the doctor's office of any changes in my medical status. I also authorize the healthcare staff to perform the necessary services I may need.