If you need the above requested form(s) to be faxed, please complete the fields below. Your signature and phone number are required as well.
I authorize Johns Creek Pediatrics to release the above requested form(s) to:
By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application
If you would like the requested form(s) sent to you electronically, we can send them via our secured patient access portal. If you need information on how to set up an account, please visit our website or call our office.
We will make 3 attempts to deliver the documents, after that, parents will be responsible for picking it up at our office
Your message will be encrypted.
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