Forms :: Cumberland Pediatrics

If this is your first visit to our office, complete our new patient information form before your first visit. Click on the link to the right to download.

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 $5 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	$10
Disability forms	$10
Letters required by school, daycare, utility companies, parents or the IRS	$10
Daycare application forms	$5
Camp, sports or college forms	$10
Transfer of records - flat fee per chart	$15*

* Parents may request a copy of GA Law 31-33-3 to clarify this policy.

Cumberland Pediatrics
1405 Franklin Road • Marietta, Georgia 30067
770.951.5400 Phone • 770.951.5408 Fax