Upload/Email Your Forms

How to upload a child’s form: 

Step 1: Fill out the Electronic Consent Form below. We cannot start processing your child’s form until this is completed. This form only needs to be completed once for each child, not once for each form. If you have already filled out this form for your child, proceed to step 2, click here.

REQUEST FOR CONFIDENTIAL ELECTRONIC COMMUNICATIONS - ELECTRONIC CONSENT FORM

Patient First Name*:
Patient Last Name*:
Patient Date of Birth*: (mm/dd/yyyy)
Date of Request*: 9/24/2017

I know that emailing personal health information to Peachtree Park Pediatrics will be delivered by non-secure email. I understand that this email is not secure and may create a risk of improper disclosure to unauthorized individuals. I am willing to accept that risk, and will not hold the practice responsible should such incident occur.

After the practice receives these forms, the process will take approximately three (3) business days to complete. Please indicate whether you would like for us to mail or upload the form, or if you would prefer to pick it up in the office.

WE WILL NOT RESPOND TO MEDICAL ADVICE QUESTIONS OR PRESCRIPTION REFILLS THROUGH THIS EMAIL.

YOU MAY ONLY SEND DOCUMENTS FOR YOUR PHYSICIAN AND FORMS THAT NEED TO BE FILLED OUT FOR SCHOOL OR CAMP.

This agreement shall remain in effect until terminated by parent/patient via written request.

Acknowledgement and Agreements:

I understand and agree that the requested communication method is not secure, making my PHI at risk for receipt by unauthorized individuals. I accept the risk and will not retaliate against the practice in any way should this occur.

Signed*:    Date*: (mm/dd/yyyy)
Phone*:
Street Address*:
City*:   State*:   Zip Code*:
Verification Code*: