GoodLife Medical Center, PLLC
1719 Kirby Parkway, Memphis, TN 38120
Do you have a
Advance Directive \ Advance Care Plan?
What is it?
How do I get one?
For these answers and more please see our ACP FAQ.
If you have any questions about these forms you can contact us at any of the locations listed below.
New Patient Information Form
All first time patients please complete the attached New Patient Packet, and bring it with you to your first office visit, along with a list of the medications you are currently taking, (if you have the bottles or containers for these medications bring those along as well).
A form of picture ID is also required, (this can include a driver's licence,
passport, student or work ID).
All current medical insurance cards (for both Primary, secondary or terciary insurance if appropriate).
A copy of any medical records you may have, either from your previous physician or from your most recent hospital visit.
Transfer of Records Form
Filling out this form helps us to make sure that we obtain the most relevant records for you from your previous doctor. Fill it out and bring it with you when you come to the office for your first visit.
Financial Policy Form
This form is our Financial Policy form. It help you understand what our financial policies are.
1719 Kirby Parkway
Memphis, TN 38120
Tel: (901) 685-1994
Fax: (901) 685-1997
1264 Wesley Drive, Suite 301
Memphis, TN 38116
Tel: (901) 345-1022
Fax: (901) 345-1033
Medication Refill Request Form
This form is to be filled out by patients that would like to request a refill on their medications. Once the form is filled out please bring it with you to your office visit.
Please note that refill requests for narcotics, antibiotics or psych medications are only performed during an office visit.
Civil Surgeon Worksheet USCIS Form I-693
Form I-693 is used to report results of a medical examination to USCIS. The examination is required to establish that an applicant is not inadmissible to the United States on public health grounds.
After completion of the medical examination, the civil surgeon is required to give you, the applicant, the completed Form I-693 in a sealed envelope.
Do not accept it if it is not in a sealed envelope. USCIS will return the form to you if it is not in a sealed envelope or if the envelope has been opened or altered.
It is the applicant’s responsibility to submit the Form I-693 to USCIS, not the civil surgeon’s.