Patient Forms

  •  Covid Consent Form to administer Covid-19 Vaccine Fulton County Consent form to administer COVID-19 vaccine
  • Patient Contact Information [PDF] [OnlinePlease complete this form if you are new to the practice or have had any recent changes to your contact information.
  • Address Change Have you moved recently? Or need to change the primary contact number for your child? Update this form and submit it to the office as soon as possible.
  • Physical Examination Form This is a standard physical examination form that many schools and camps use for physical activity and medical clearance. Many schools and camps have their own specific forms. Please verify with your institution if this form is acceptable. If so, please print out the form and either fax or mail to our office or bring the form with your during the visit. Please note that the first page needs to be filled out to its entirety by the patient/participant or parent(s) before the physician can fill out his/her section.
  • Referral Form (Pre-Authorization) If your insurance requires pre-authorization for appointments or procedures with a specialist, please complete this form and return it to our office at least 3 days prior to your appointment with the specialist.
  • Medical Proxy [PDF] [Online] for Minor Patients Complete this form if your child is under the age of 18 and may come to office to seeK medical care alone or with an adult other than a custodial parent/guardian.
  • Request Medical Records to Be Transferred In [PDF] [Online] Use this form if you are transferring the care of your child to this practice and need records from another pediatrician.
  • Request for Medical Records to Be Transferred Out Use this form if you are transferring the care of your child to another provider.
  • Release of Information Form [Online] Use this form to obtain medical records from a specialist.

Contact Us

If your child is sick and needs an appointment today, call the office at 404-261-2666.

Our Location

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Hours of Operation

Our Regular Schedule

Atlanta Children's Clinical Center

Monday - Friday:

8:30 am - 5:00 pm


9:00 am - 12:00 pm