OUR LOCATION 3515 Dallas Highway Suite C Marietta, GA 30064 (P)  770-943-9150 (F)  770-218-0278 Office Hours M/T/Thu/Fri: 9-5 Wed: 9-1 Lunch: 1-2	Patient Forms Page We offer a number of forms in PDF format that you can download (using the free Adobe Reader software) and print out. Filling out these forms prior to your office visit can save you time. The BRIGHT FUTURES and DEMOGRAPHICS forms are especially important and should be completed before your visit. DEMOGRAPHICS (FAMILY REGISTRATION FORM) BRIGHT FUTURES FORMS 2-5 DAY BRIGHT FUTURES 1 MONTH BRIGHT FUTURES 2 MONTH BRIGHT FUTURES 6 MONTH BRIGHT FUTURES 9 MONTH BRIGHT FUTURES 12 MONTH BRIGHT FUURES 15 MONTH BRIGHT FUTURES 18 MONTH BRIGHT FUTURES 2 YEAR BRIGHT FUTURES 3 YEAR BRIGHT FUTURES 4 YEAR BRIGHT FUTURES 5 YEAR BRIGHT FUTURES 6 YEAR BRIGHT FUTURES 7 YEAR BRIGHT FUTURES 8 YEAR BRIGHT FUTURES 9 YEAR BRIGHT FUTURES 10 YEAR BRIGHT FUTURES 11-12 YEAR BRIGHT FUTURES 13-14 YEAR BRIGHT FUTURES 15-17 YEAR BRIGHT FUTURES 18-21 YEAR BRIGHT FUTURES Patient Information/Insurance We do not accept Peach State, Ambetter, Kaiser, Amerigroup or Humana HMO Transfer of Medical Records This is how we obtain your old medical records from previous physicans' offices. Medical Records Release Permission to Send Records Click Here for Medical Records Request Form for Treatment Purposes PLEASE NOTE: You do not have to have your previous doctors' medical records with you at your initial visit. Notice of Privacy Practices As required by the privacy regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Notice of Privacy Practices (Rev. 7/16/11) Other Forms Medication Questionnaire Medication Check Questionnaire Receipt of Notice of Privacy Practices Written Acknowledgement Form (Rev. 7/16/11) Financial Policy Form (Rev. 7/18/11)

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