Forms

Forms for GPAM Families

• Pre-Visit Check-in
• Policies & Patient Forms
• Katie Beckett & FMLA Forms
• Medical Records Release
• Patient Satisfaction Survey
• Medical Referral Request
• Travel Visit Questionnaire

Pre-Visit Check-in

Patient forms will be available for your completion 1 to 2 days before your scheduled appointment and the day of your scheduled appointment.

You will receive an email and a text with a link to start your secure pre-visit check-in. This can be done from a desktop or your mobile device. If you do not complete the check-in process prior to your appointment, you will receive another email and text on the day of the appointment.

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It is very important that you complete the secure pre-visit check-in forms before you arrive at your appointment.

If you need to pick up forms, please arrive at the office between 8:15 a.m. and 12:00 p.m. or between 1:15 p.m. and 4:30 p.m. on weekdays. If you need to pick up forms at another time, please call the main phone line at 770-995-0823 to make arrangements.

Office Policies and Other Patient Forms

• Financial Policy
• Divorced/Separated Parents Policy
• Consent to Treat
• ADHD Packet

School and Sports/Camp Forms

Please note: The parent must complete all parent/patient sections of the form before sending it in for completion.

School Forms

GA FORM 3231 Immunizations and GA 3300 Hearing and Vision Forms

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You can request this form through the patient portal or by calling 770-995-0823 and selecting the immunization records option. It is important to give us 48 hours’ notice, especially during peak school registration periods.

All immunization and hearing and vision forms needed for school are completed FREE.

If your child is out of school because of illness, we will provide you a school or work excuse for that illness.

Sports & Camp Forms

We will be happy to complete your sports form at no charge if your child has had a regular annual checkup within a year. Some forms may ask for heart rate before and after exercise. If so, a nurse appointment will need to be scheduled. Bring your sports form with you to your check up visit for faster completion.

We will complete sports and camp forms within 48 to 72 business hours. Forms needed within 24 hours are subject to a fee.

• Sports Physical Form
• Special Olympics Form

Katie Beckett & FMLA Forms

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Katie Beckett or FMLA forms for parents are completed for a fee of $25.00 per form.

Medical Records

If you wish, you can download a copy of your child’s medical records through the patient portal. To do so, you must log onto the patient portal through a desktop (not mobile).

• Click on my health, then health records.
• Select what you wish to obtain and enter the email address you want it sent to.
• You will then receive and secure attachment of your records.
• You can also view, download, or print specific visits by clicking on care summaries, you can toggle between dates on the drop-down menu.

How do I release records to another practice?

You can download or email records to your new office through the patient portal directly as directed above. If you would like for us to still print the records or forward them to another practice, please complete the release form and send it to the office via fax at 770-995-7018. All records are released within 7 business days.

• Medical Records Release

Can I get a copy of my child’s records for myself?

Yes, records can be released directly as a digital copy (such as CD or USB flash drive). You will still need to submit the request by completing the release form. There is a search and retrieval $20 fee for medical records released directly to you. This charge is based on Georgia Law. If you need your records to be certified, there is an additional $9.70 fee. All fees will need to be collected before release. To make a payment call our billing department or stop by the office.

How do I release records to Gwinnett Pediatrics?

For best patient care, it is preferred that records are transferred to us prior to your appointment. Our providers like to review the records and learn your child’s medical history so you get the best care out of your appointment time. You can complete our release form above and then send it to your previous pediatrician to forward records to us.

Online Forms

• Patient Satisfaction Survey
• Medical Referral Request
• Travel Visit Questionnaire – Complete this form if you are traveling out of the country.

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