Sprayberry Pediatrics Consultation Request for Non-Members

Emergency Contact Information

Past Medical History

Family History

Birth History (complete if patient is under 3 years old)

Acknowledgement that Sprayberry Pediatrics, Dr. Sprayberry, and Dr. Miller are not the patient's primary physician

By typing my name below, I acknowledge that Sprayberry Pediatrics, Dr. Sprayberry, and Dr. Miller are NOT becoming the patient's primary physician. I acknowledge that this visit is a one-time service that creates no obligation or expectation of future visits of follow-up of this visit. I acknowledge that Sprayberry Pediatrics is not committing to provide after hours care, hospital care, or any other care that does not occur during the time of the scheduled consultation.

Financial Responsibility

Who is financially responsible for any bills that may occur as a result of your child's visit to Sprayberry Pediatrics?

Acknowledgement of Financial Responsibility

By typing my name below, I acknowledge that I am responsible for all charges incurred by this visit and the fee is nonrefundable and is due before the visit is performed. I also acknowledge that the fee for this service is $400 for up to 1 hour of consultation time. Consultations that surpass the allotted 1 hour, will be billed for a second hour at $400/hour. I also acknowledge that any labs or procedures performed at the visit will be charged at the then current a la carte charge (fees available on request) in addition to the consultation fee.

GENERAL CONSENT TO TREATMENT

SPRAYBERRY HEALTH LLC d/b/a SPRAYBERRY PEDIATRICS

IMPORTANT:
DO NOT SIGN THIS FORM WITHOUT READING AND UNDERSTANDING ITS CONTENTS

This General Consent to Treatment (“Consent”) is given to Sprayberry Health LLC d/b/a Sprayberry Pediatrics (the “Practice”) by the parent or legal guardian signing below (“you”).

1. Authority to Consent. You represent that you are, whether as the parent or legal guardian of the child or children identified below (each, the “Child”) or otherwise, authorized to consent to the Child's medical care under applicable Georgia law. You agree to notify the Practice of any court order, custody arrangement, or facts that affect your authority to consent to the Child's care or to access the Child's records.

2. Consent to Routine Care. You consent to the Practice's physicians and other qualified clinical personnel providing routine pediatric medical care and services to the Child as they consider necessary and appropriate in the exercise of their professional judgment, and to the prescribing and administration of medications as needed to treat the Child's health conditions.

Routine care includes, by way of example, history and physical examinations; well-child and preventive visits; evaluation and treatment of illness and injury; immunizations and injections; collection of specimens for testing (including blood draws, finger or heel sticks, and throat, nasal, or other swabs); point-of-care testing; laboratory testing; diagnostic imaging; electrocardiograms (EKGs); and medically appropriate minor in-office procedures such as wound care.

This consent extends to care the Practice's clinicians determine is reasonably necessary in their professional judgment, including care that was unforeseen or not known to be needed when this Consent was signed, and to conditions that arise during the course of care. Care may be provided by a physician or, under appropriate physician supervision, by other qualified clinical personnel of the Practice.

3. Physical Examination Acknowledgment. You understand that age-appropriate physical examination of the Child, including an external genital examination, is a routine and accepted part of pediatric well-child and other care, performed in accordance with accepted professional standards and, as appropriate, with a chaperone present. Unless you initial below to decline, you consent to such examination as part of the Child's care.

By initialing below, I decline consent to an external genital examination as part of routine care, and I understand the Practice will discuss with me how this affects the Child's care.

4. Presence at Visits. The Practice will examine or treat a Child under 18 years of age only when a parent, legal guardian, or a person authorized under Section 11 is present at the visit. In an emergency, the Practice may provide care as described in Section 5.

5. Emergency Care. If the Child experiences a medical emergency while in the Practice's care, you authorize the Practice's clinicians to provide care reasonably necessary to address the emergency and to arrange emergency medical services or transport to a hospital. The Practice will make reasonable efforts to contact you as soon as possible. The Practice is not an emergency facility; in any emergency, you should call 911 or go to the nearest emergency department.

6. Digital Images. Digital or other images of the Child (for example, photographs of a rash, lesion, or wound) may be made to document the Child's care, and you consent to such images being made and kept as part of the Child's medical record. The Practice retains ownership of these images, stores them securely, and retains them as required by law and Practice policy. Images that identify the Child will not be used or released outside the Practice for teaching, publication, or any non-treatment purpose without your separate written authorization.

7. Procedures Requiring Separate Consent. This Consent covers routine care only. It does not authorize surgery, anesthesia, or other procedures or treatments for which Georgia law requires separate written informed consent. For any such procedure, the treating physician will obtain a separate informed consent.

8. No Guarantees. The practice of medicine is not an exact science, and no guarantees or assurances have been made to you concerning the outcome or result of any care or service. Even routine care, such as immunizations, injections, and minor procedures, carries some risk, and the Practice cannot guarantee any particular result.

9. Right to Ask Questions; Withdraw Consent. You have the right to ask questions about any proposed care or treatment - including the identity and role of any person providing care - at any time. You may withdraw this Consent at any time by notifying the Practice in writing. Withdrawal will not affect care previously provided in reliance on this Consent.

10. Accurate Information. The Practice's clinicians will rely on the Child's documented medical history and on information you provide. You agree to provide accurate and complete information about the Child's medical history and condition.

11. Validity. This Consent is valid for so long as the Child is a patient of the Practice and applies to care provided during that period unless it is withdrawn in accordance with Section 9. A copy or electronic version of this Consent is as valid as the original.

Acknowledgment

I certify that I have read this Consent, that any questions I had about its contents have been answered, and that I fully understand its contents.

I am authorized to consent to the Child's care, and I consent to care as described above.

The Practice is entitled to rely upon the representations and authorizations contained in this Consent unless and until it receives written notice of any change.

SPRAYBERRY HEALTH LLC d/b/a SPRAYBERRY PEDIATRICS NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU OR YOUR CHILD MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY.

Effective Date: 8/19/2026

Our Duties

Sprayberry Health LLC d/b/a Sprayberry Pediatrics (the “Practice, ” “we, ” “us”) is required by the Health Insurance Portability and Accountability Act (“HIPAA”) and other applicable law and regulations to maintain the privacy and security of your child's protected health information (“PHI”), to give you this Notice of our legal duties and privacy practices with respect to PHI, and to notify you following a breach of unsecured PHI. We are required to abide by the terms of the Notice currently in effect. This Notice describes how we may use and disclose your child’s PHI and our privacy practices and your rights regarding PHI. Because this is a pediatric practice, the patient is ordinarily a minor child, and this Notice refers to "you" as the parent or legal guardian acting on the child's behalf, except where the child has the right to act for themselves under law.

How We May Use and Disclose PHI Without Your Authorization

Treatment. We use and disclose PHI to provide, coordinate, and manage your child's care, including sharing information with other providers involved in that care, such as specialists, laboratories, or a hospital, and including care delivered by telehealth.

Payment. We are a cash-pay practice and do not bill health insurers. We use PHI to charge and collect the fees for your child's care - for example, processing payment through our payment processor. We do not submit claims to, or seek payment from, any health insurer or government program.

Health Care Operations. We use and disclose PHI to run the Practice - for example, quality review, training, care coordination, scheduling, and administrative functions.

Business Associates. We may share PHI with vendors who perform services for us (such as our payment processor, electronic records system, or telehealth platform), each of which is required by a written agreement to protect PHI.

Appointment Reminders and Communications. We may use PHI to contact you about appointments, results, and your child's care, including by phone, email, and text as you have authorized.

As Required by Law; Public Health and Safety. We may use or disclose PHI when required by law, including: reporting suspected child abuse or neglect under O.C.G.A. § 19-7-5; public-health activities; responding to a valid subpoena, court order, or law-enforcement request as permitted by law; preventing a serious threat to health or safety; and health-oversight activities. We will limit such disclosures to what the law requires or permits.

Persons Involved in Care. Unless you object, we may share relevant PHI with a family member or other person you involve in your child's care.

Other Uses and Disclosures That Require Your Written Authorization

Most uses and disclosures not described above will be made only with your written authorization, which you may revoke at any time (except to the extent we have already acted on it). This includes any sale of PHI, psychotherapy notes (where applicable), and marketing communications and other disclosures for which authorization is required by applicable law. Communications about the Practice's own products and services, your child's care, refill reminders, and similar communications are generally not "marketing" requiring authorization.

To the extent maintained by the Practice, certain categories of information - including substance use disorder records, HIV/AIDS-related information, mental health information, genetic information, and certain reproductive health care information – may have additional legal protections and require specific authorization before we disclose them.

Your Rights

Access and Copies. You have the right to inspect and obtain a copy of your child's records, consistent with O.C.G.A. § 31-33-2 (records furnished within 30 days of a written request, with charges as allowed by O.C.G.A. § 31-33-3).

Amendment. You may request that we amend PHI you believe is incorrect or incomplete; we may deny the request in certain circumstances and will explain why.

Accounting of Disclosures. You may request a list of certain disclosures we have made, other than those for treatment, payment, operations, and certain others.

Request Restrictions. You may ask us to restrict how we use or disclose PHI. We are not required to agree, except that we must agree to a request not to disclose PHI to a health plan for a service you paid out of pocket. Because we are a cash-pay practice and do not bill insurers, PHI about your child's care is not disclosed to any health plan in the ordinary course.

Confidential Communications. You may ask us to communicate with you by alternative means or at an alternative location, and we will accommodate reasonable requests.

Paper Copy. You may request a paper copy of this Notice at any time, even if you agreed to receive it electronically.

Choose Someone to Act for You. A parent, legal guardian, or person with legal authority may exercise these rights on the child's behalf, to the extent allowed by law.

Complaints. You may complain to us or to the U.S. Department of Health and Human Services, Office for Civil Rights, if you believe your privacy rights have been violated. To file a complaint with us, contact our Privacy Officer at the address or phone number below. We will not retaliate against you for filing a complaint.

Minors and Parents

In most cases a parent or legal guardian is the child's personal representative and may exercise these rights for the child. In the limited circumstances where Georgia law allows a minor to consent to their own care, the minor may control the related information, and a parent's access may be limited accordingly. In those circumstances, the Practice may be prohibited from disclosing the information to a parent or guardian without the minor's authorization.

Breach Notification

We will notify you without unreasonable delay upon our discovery of a breach that compromises the privacy or security of your child's unsecured PHI, as required by law.

Changes to This Notice

We reserve the right to change this Notice and to make the revised Notice effective for PHI we maintain, including PHI created or retained before the change. The revised Notice will be posted in our office and on our website, and a copy will be available on request.

Contact

Privacy Officer: David R. Sprayberry, MD, CEO, Sprayberry Health LLC, 1618 Mars Hill Rd, Suite A, Watkinsville, GA 30677. Phone: 470-780-2004; Email: info@sprayberrypediatrics.com

SPRAYBERRY HEALTH, LLC d/b/a SPRAYBERRY PEDIATRICS

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I acknowledge that I have received or been offered a copy of the Notice of Privacy Practices of Sprayberry Health LLC d/b/a Sprayberry Pediatrics, which describes how the Practice may use and disclose health information about my child and my rights regarding that information.

For Practice use only (if acknowledgment is not signed):

A good-faith effort was made to obtain the parent's/guardian's written acknowledgment of receipt of the Notice of Privacy Practices, and acknowledgment was not obtained for the following reason:

☐ Declined to sign ☐ Emergency/urgent visit ☐ Other: __________________________

Staff name: ________________________________ Date: ________________