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Medical Record Release Form

By signing this form, I authorize you to release confidential health information about my Childs Immunization Records to Tennessee Toddles Drop In Day Care.

Child's First Name

Child's Last Name

Child's Birthday

Pediatrician Name

Pediatrician Phone Number

Release my Childs protected health information/immunization records to:

Tennessee Toddles
7036 City Center Way, Fairview, TN 37062

Parent First Name

Parent Last Name

Parent Phone Number

Parent Email

Thanks for submitting!
We’ll contact this person only in case of emergency.

Contact Us

Hours

7036 City Center Way

Fairview, TN 37062

615-266-2597

Monday-9:00 am-5:00 pm

Tuesday-9:00 am-5:00 pm

Wednesday-9:00 am-5:00 pm

Thursday-9:00 am-7:00 pm

Friday-9:00 am-7:00pm

Saturday-9:00 am-7:00 pm

Sunday-9:00 am-7:00 pm

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© 2023 by Tennessee Toddles. TN Toddles

Refund Policy - All Sales With Tennessee Toddles Are Final.

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