New Patient Packet (Pages 1-11)

Well Visit and Additional Charges Form

Request for Records Release TO Dunwoody Pediatrics

Request for Records Release FROM Dunwoody Pediatrics

IF YOU ARE RELOCATING TO ANOTHER PEDIATRICIAN, WE SUGGEST REQUESTING THE LAST 2 WELL AND SICK VISITS, CURRENT IMMUNIZATIONS, MEDICATION LIST AND PROBLEM LIST TO PROVIDE YOUR NEW PEDIATRCIAN WITH THE INFORMATION THEY NEED FOR CONTINUITY OF CARE. THERE IS NO CHARGE FOR THESE LIMITED RECORDS.

IF YOU WOULD LIKE YOUR CHILD'S COMPLETE MEDICAL RECORD, THERE WILL BE A $6.50 CHARGE AND WE ARE HAPPY TO SEND THIS TO YOU VIA SECURE EMAIL OR OUR PATIENT PORTAL FOR YOU TO PRINT OUT FOR YOUR NEW PEDIATRICIAN. BECAUSE WE HAVE ELECTRONIC MEDICAL RECORDS, WE WILL NO LONGER FAX RECORDS TO ANOTHER OFFICE BUT ARE HAPPY TO SEND TO ANOTHER OFFICE VIA SECURE EMAIL

PLEASE COMPLETE THE "REQUEST FOR RECORDS FROM DUNWOODY PEDIATRICS" AND SUBMIT TO OUR OFFICE FOR PROCESSING.

• 2020 GHSA Physical Form
• Edinburgh Postnatal Depression Scale
• MCHAT
• PHQ-9 (Adult)
• PHQ-9 (Modified for Teens)

PLEASE CONTACT OFFICE  ABOUT OUR POLICIES FOR COMPLETION OF THESE FORMS AND SCHEDULING CONSULT APPOINTMENTS TO REVIEW RESULTS.

ADHD Parent Initial Form

ADHD Parent Follow-Up Form

ADHD Teacher Initial Form

ADHD Teacher Follow-Up Form

ADHD Adolescents - to be completed by patient

• 2 Month Questionnaire
• 4 Month Questionnaire
• 6 Month Questionnaire
• 9 Month Questionnaire
• 12 Month Questionnaire
• 14 Month Questionnaire
• 16 Month Questionnaire
• 18 Month Questionnaire
• 24 Month Questionnaire
• 24 Month MCHAT
• 30 Month Questionnaire
• 36 Month Questionnaire
• 48 Month Questionnaire
• 60 Month Questionnaire

• Patient Information Form
• HIPAA 18 or Older Consent Form
• Well Visit and Additional Charges Form

• Patient Information Form
• Well Visit and Additional Charges Form

• Generalized Anxiety Disorder - GAD-7
• SCARED Anxiety Screen (child to complete)
• SCARED Anxiety Screen (parents to complete)
• Columbia Depression Scale - Child Form
• Columbia Depression Scale - Parent Form
• PHQ-9

• Covid-Fact-Sheet-ages-12+
• Covid-Fact-Sheet-6-mo-11-years

• Patient Information Form
• HIPAA 18 or Older Consent Form
• Non-Covered Services - Well Check
• Well Visit and Additional Charges Form

• Patient Information Form
• Non-Covered Services - Well Check
• Well Visit and Additional Charges Form

Effective 11/1/22, our forms fee policy is as follows:

• FORMS CANNOT BE COMPLETED SOONER THAN 7 BUSINESS DAYS AND ARE GUARANTEED TO BE COMPLETED BY THE 10TH BUSINESS DAY AFTER RECEIPT!! PLEASE MAKE SURE YOUR CHILD IS ALSO AWARE OF THIS TURNAROUD TIME AND GIVES YOU THE FORM WITH ENOUGH TIME FOR US TO COMPLETE.
• Your physician will complete for free one participation form (sports, camp.etc) at your child's annual physical exam. Please bring form with you to visit, WITH YOUR PORTION COMPLETED IN ADVANCE.
• For any participation forms in additional to this one free form or FMLA, disability forms or letters requesting special consideration for your child, there will be a $10 charge per form.
• For Katie Beckett forms, there will be a $25 charge.