Download and print out the forms you need at your convenience.
Forms
Please be aware with recent changes and requirements from other facilities that require a child to have a specific form. For example prescription pre authorization letters, letters of medical necessity, schools, sports, county forms, medication at school form, day care, etc., we are requiring a payment PRIOR to needing a form or letter filled out and signed.
We ask that you give the staff and providers a 72hr time frame to complete our portion of these forms. This will give them time to review your child’s chart for all of their medical history. So please plan ahead.
Please be sure that YOU fill out your portion of these forms first BEFORE you drop them off and be aware there will be a “per” form fee to be paid at the time of drop off.
We appreciate your patience and understanding with this policy.
Forms in English
New Patient Form Packet (Birth-5yrs)- New Patient Form Packet (5yrs and older)
- Privacy Practices
- Authorization to Treat Minor Without Parent Form
- Medical Record Release form to NFP
An immunization record, growth chart, and problem list can be provided at no charge. Otherwise, there will be an administration fee charged for each child's records to be transferred.
If you would like to receive copies of your child's records from our office, we will need a signed release form from the parent or guardian that must be faxed to us at 770-475-1621. - Medical Records Release to be sent
- Preparticipation Physical Evaluation Form
There is a $10.00 fee (paid in advance) for all forms to be completed by our office. Please allow 72 hours to get these forms completed. Thank you in advance for your understanding. This form needs to be filled out by the parent and faxed to us at 770-475-1621.
- Teen Driver Contract
- Health Assessment Form (Birth-5 months)
- Health Assessment Form (6-9 months)
- Health Assessment Form (12-18 months)
- Health Assessment Form (up to 24/30 months)
- Health Assessment Form (3-5 years)
- Health Assessment Form (6-11 years)
- Health Assessment Form (12-18 years)
Formas en Español
- Nacimiento de la edad a 5 años de paquete de la forma
- Edad 5 años y un paquete más viejo de la forma
- Reconocimiento (Birth-5 months)
- Reconocimiento (6-9 months)
- Reconocimiento (12-18 months)
- Reconocimiento (up to 24 months)
- Reconocimiento (3-5 years)
- Reconocimiento (6-11 years)
- Reconocimiento (12-18 years)