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.
