Patient Forms

Patient Registration

If this is your first visit to our office, complete our patient registration packet before your first visit.

• Patient Registration - English
• Patient Registration - en Español

Individual Forms

• Medical Records Release - English
• Medical Records Release - en Español
• Temporary Authorization of Consent to Treat a Child
• Notice of Privacy Practices

Other Forms

• Forms Request - English
• Forms Request - en Español

Please note that if you do not receive a 3231 Form or Visual & Hearing Form at the time of your child’s check-up, there will be a $10 charge for each form.

Other forms required by schools, offices, daycare or other organizations will require a fee.

Forms requiring ONLY a physician's signature, no charge.

Work form for parents - $15.00
Disability forms - $15.00
Letters required by the following: - $15.00

• School
• Daycare
• IRS

Daycare application forms - $15.00
Camp, sports or college forms - $15.00

Transfer of records - There is no charge if transferring physician to physician. Otherwise, Cumberland Pediatrics charges a fee per page.
*Copy of GA Law 31-33-3 to clarify this policy.