Priority Pediatrics PC

Available Forms

1. NEW Patient Online Intake History Form for Dr. T 2. ESTABLISHED Patient Online Interim History Form for Dr. T 3. Lead Exposure Risk Questionnaire for parent to complete for Dr. T 4. Request to Transfer Medical Records to Priority Pediatrics 5. Pediatric Symptom Checklist for PARENTS of 11-18 Year Olds to Complete for Dr. T 6. Pediatric Symptom Checklist for YOUTH ages 11-18 Years to Complete for Dr. T 7. Adolescent Mood Questionnaire for the Teen to complete for Dr. T 8 Side Effect Patient Check List 9. Tuberculosis (TB) Exposure Risk Questionnaire to complete for Dr. T 10. Pediatric Sleep Questionnaire / PSQ for parent to complete for Dr. T

4. Request to Transfer Medical Records to Priority Pediatrics

Please Print this Form when completed & forward this form by fax, mail or electronically to your child's or children's current pediatrician(s), who will then send medical records to Dr. Tanenbaum @ Priority Pediatrics PC. You can also use this form to request medical records from specialists, hospitals, psychologists, school personnel or other health personnel & facilities.

Name of Patient(s): *

Please separate each name with a comma and relate to the dates of birth in next item is the same sequence.

Date(s) of Birth:

Please list dates of birth for each patient listed above in the same sequence.

To Name of Practice/Health Professional for request of Medical Records: *

From: Priority Pediatrics, PC_This notice is to request the Medical Records from your Office be sent to Dr. Marc A. Tanenbaum, Priority Pediatrics PC.

The records can be on CD in digital format (Word documents or PDF's) or paper. Please include Immunizations, Problem List, Dates and Summaries of Hospitalizations, Important Summaries to and from consultants, Lab and Xray, etc.

Please Fax to 678-806-0900 or mail these records (CD/paper) to:

Priority Pediatrics, PC, Box # 202, 6300 Powers Ferry Road, Suite 600, Atlanta, GA 30339

Thank you,

___________________________________________________

Custodial Signature(s) & Relationship(s) to Patient(s)

Date *

Date

Telephone(s): *

Please remember that on completion of this form to print as many copies as you need & then mail them to your child's current health professional(s) to request that records be sent to Dr. T at Priority Pediatrics PC, #202, 6300 Powers Ferry Rd, Suite 600, Atlanta, GA 30339.

* Required field