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1405 Franklin Gateway
Marietta, GA 30067

Cumberland Pediatrics, Pediatricians in Marietta, Smyrna

Phone: 770-951-5400 | 1405 Franklin Gateway • Marietta, GA 30067 | Directions

Patient Forms

New Patient Packet

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

Individual Forms

Specialized Forms

Strong 4 Life Healthy Habits Assessment Forms

Attention Deficit Disorder Assessment Forms

Allergy Forms

Autism Checklist

Other Forms

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 - $10.00
Disability forms - $10.00
Letters required by the following: - $10.00

  • School
  • Daycare
  • IRS

Daycare application forms - $10.00
Camp, sports or college forms - $10.00
Transfer of records - flat fee per chart - $15.00

*Parents may request a copy of GA Law 31-33-3 to clarify this policy.