New Patients
Prior to your first appointment you will receive an email with a link to all the forms you’ll need to complete before your first visit. This link will also allow you to electronically sign and return documents securely.
If you are not able to complete forms through the link sent to you, you may also print them below to complete at home and bring with you to your first visit. If you plan to complete the forms in the office, please arrive early enough to allow time for completion before your appointment.
Existing Patients
Update Current Registration Information: Registration Update
Individual Forms
Patient Authorization Signatures 2018
Medical Records Release IN to KP 2018– Authorizes us to receive records from an outside organization or other medical practice
Medical Records Release FROM KP 2018 Authorizes us to release records to an outside organization such as a school, daycare or other medical practice
Electronic Request via Patient Portal
Many requests for records can be made through our patient portal. These include requests for referrals, immunization records requests and hearing and vision records requests. Simply sign into the patient portal and send us an email request for any of these items.
Referral Request – To complete this form you will need the following information about the specialist you are being referred to: specialist’s name (or if scheduled with a physician’s assistant or nurse practitioner, their supervising physician), date of the appointment, address and phone / fax number of practice.
Immunization Records Request (3231) – If this will be released to an outside organization, you’ll also need to complete the Medical Records Release FROM KP. This form requires 48-72 hours for completion. This is a state form that certifies a child is up to date on immunizations, therefore your child must be fully up to date on all required immunizations for us to issue this form.
Hearing and Vision Records Request (3300)– If this will be released to an outside organization, you’ll also need to complete the Medical Records Release FROM KP. This form requires 48-72 hours for completion. For us to complete this form, your child MUST be up to date on their well-child visit AND have a valid hearing and vision exam within the last 12 months.
Katie Beckett Forms
These require 7-14 business days for completion. Your child must be up to date with their well child exams and have any/all supporting documentation from specialists, labs, therapist, and counselors on file with Kennesaw Pediatrics. These comprehensive forms require a great deal of time and review. You are responsible for ensuring all appropriate documentation is present at the time of your request.
Family Medical Leave Act (FMLA) Form
This form requires 7-14 business days for completion.
FORM FEES
Immunization Records (3231) are provided at each well check, free of charge. Hearing and Vision Forms (3300) are also provided free of charge at any visit in which hearing and vision are checked. Sports or camp forms brought to the exam are also completed free of charge. Replacement 3231 or 3300 forms, or other forms that are dropped off for completion at a time other than an exam, are $10 per form. Because of the substantial time involved in completion, initial Katie Beckett applications are $75.