Forms

The information you provide can be very helpful to understand your children’s or family’s medical history or concerns. Most screening tools, fortunately, reassure parents that their child is normal and at low risk of serious medical conditions. Sometimes, we need to investigate further based on the information provided and your child’s physical exam.

New Patient Forms
Please complete the following forms and bring to your child’s first office visit:

Practice Agreement – HIPAA and Billing Policies (read only)
Practice Consent Form (sign and bring in)
Insurance and Finance Policy (initial, sign and bring in)
Medical History (please complete for each child and bring in)
Request Medical Records (to request medical records from your previous pediatrician – request in advance of 1st visit)

Well-Visits Forms
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: 18mo and 2yo)
PEDS Development Questionnaire (for well-visits: 9mo, 18mo, 2yo and 3yo)
Pediatric Cardiac Risk Assessment (for well-visits: 5yo, 11yo, 14yo)
Tuberculosis Risk Assessment (Medicaid patients only – all well-visits)

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 the Adolescent Health Survey form (if your child is 13yo or older) and bring this with you to your office exam.

Prenatal Forms
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 Forms
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 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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