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

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 - $15.00
Disability forms - $15.00
Letters required by the following: - $15.00

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.