Forms

Complete the forms below that are relevant to your child’s visit. Most can be complete in advance and emailed or faxed.  Email to:   Fax to: 770-988-5553. Or you can drop them off at the office. If you are sending electronic format, we prefer PDF files. (see notes below on creating a PDF). The PDF forms that can be completed online are indicated in green. You do not need to print these, you can complete online, save and email to us. If using Adobe, use the Fill & Sign mode.

New Patient Visits
These forms must be complete prior to your first appointment. You can fax, email or drop off the forms at the office. After we create your patient records, we will call you to set your appointment:
Practice Agreement – HIPAA and Billing Policies (read only-you do not need to bring in)
Patient Contact and Consent Form (Online form: complete one per family)
Patient Contact and Consent Form for 18 year old (Online form: for a patient 18 years or older to complete)
Insurance and Finance Policy (one per family, initial, sign)
Medical History (complete for each child)
Request Medical Records (to request medical records from your previous pediatrician – request in advance of 1st visit)

Well-Visits (1 month to 10 years old)
To expedite your visit, the forms below can be completed in advance of your child’s well-visit:
Questions for the Doctor Optional (checklist of specific concerns or medical/developmental topics you would like addressed during your child’s appointment)
Autism Screening Form (for well-visit ages: 18 mo and 2 yo)
Pediatric Cardiac Risk Assessment (for well-visits: 5 yo, 11 yo, 14 yo)
Postnatal Depression Screen (for Mothers of 1, 2, 4, 6 month old infants)
Tuberculosis/Lead Risk Assessment (for Well-visits for Medicaid patients only)
Postnatal Depression Screen (for Mothers of 1, 2, 4, 6 month old infants)

PEDS Development Questionnaire you will receive this form at the office to complete (for well-visits: 9 mo, 18 mo, 30 mo)

Adolescent Well Visits (11 years and older)
Complete either the Adolescent Health Survey form for 11,12 yo or the Adolescent Health Survey form for 13+ yo. (Online form: you can either email to address above or print and bring with you.) These forms must be complete before the doctor sees you.

Newborn Visits
These forms should be complete before your appointment.
Practice Agreement – HIPAA and Billing Policies (read only-you do not need to bring in)
Patient Contact and Consent Form (complete one per family)
Newborn Medical History
Newborn Insurance Form
Also, please bring:
Hospital discharge forms
Insurance card – be sure to add your newborn to your policy

Prenatal Visit
Congratulations on your upcoming delivery! Dr. Bergman looks forward to meeting prospective parents at the office for a no-fee prenatal visit. Please complete this Prenatal Consultation Form and bring to your office visit or scan and email before your visit.

Asthma Followup
Complete one of these forms for your child’s periodic asthma visits: Asthma Control Test 4 to 11 years old or the Asthma Control Test for 12 years and older.
Meet and Greet Visit
If you are considering changing your pediatric practice affiliation, you have the option to schedule a “Meet and Greet” visit (no fee) to meet with Dr. Bergman. Please complete a Medical History Form for each child.

School Forms
Georgia Immunization Form (3231) – this form is printed by our practice based on immunization data that is entered by physician offices or county health departments into the Georgia Computerized Immunization Registry, known as GRITS.

Hearing/Vision/Dental Form (3300) – this form is completed during your child’s well-visit exam and dental exam.
Forms 3231 and 3300 are completed by my office staff for day care or school entry requirements.

Sports Physical Form – Complete the History Form (pages 1-2) with your child. We will complete Physical Exam and Medical Eligibility forms. You can complete the form online, save and email to or print and bring to the office.

Leaving the Practice
If you are leaving the practice, we will release a patient’s medical records for a processing fee of $20. Complete the Medical Record Release Form and email, fax, mail or deliver in person. If you would like just the immunizations records, we can process it free of charge.

Creating a PDF        If you are using a printer with scanner capabilities, the scanner should have a PDF format. You can scan the completed forms as PDF then email or fax them.    If you don’t have a scanner, you can create a PDF using your smart phone. The phone app will use the camera to generate a PDF that you can email.  For android devices or PC, use Google Drive (add a document using “+” then select Scan). For Apple devices (iOS 11or higher), use Notes (create a new note, then select “+” or camera, then Scan).

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