Forms

These forms provide information that can be very helpful to understand your children’s or family’s medical history or concerns. Please complete the forms relevant to your child’s visit. You can complete them in advance and email them to: or bring them with you.

New Patient Visits
Please complete the following forms prior to scheduling your first appointment. It would be helpful to fax or email the forms before the appointment. If not, you can print them and bring with you:
Practice Agreement – HIPAA and Billing Policies (read only-you do not need to bring in)
Practice Consent Form (sign)
Insurance and Finance Policy (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
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)
PEDS Development Questionnaire you will receive this form at the office to complete (for well-visits: 9 mo, 18 mo, 30 mo)
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 (All well-visits for Medicaid patients only)
Postnatal Depression Screen (for Mothers of 1, 2, 4, 6 month old infants)

Newborn Visits
Please complete and email or fax before your appointment. Or, print and bring with you:
Newborn Medical History
Newborn Insurance Form
Also, please bring:
Hospital discharge forms
Insurance card – be sure to add your newborn to your policy

Adolescent Visits
Your teenager’s annual well-visit is an opportunity to address a variety of possible physical, psychological, educational and social concerns; please complete either the Adolescent Health Survey form for 11,12 yo or the Adolescent Health Survey form for 13+ yo  and bring this with you to your office exam.

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.

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 (known as the Pre-participation Physical Evaluation) – the medical history section is completed by the child or parent prior to your visit; the physical exam and clearance sections are completed by your child’s pediatrician on examination in the office. This form is required for participation in Georgia middle school and high school organized athletic programs. Some community/club sports programs may require this form as well.

Leaving the Practice
If you are leaving the practice, we will release a patient’s medical records for a processing fee of $20 if your account is up to date. 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 as long as your account is up to date.

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