Georgetown Pediatrics serves Georgetown and surrounding areas in pediatric services. H. Hambrick, D. Hoddy, K. Menke, J. Riebel, A. Quackenbush, B. Badger, J. Oliver

The following forms are for your benefit. Please download the form or copy and print and bring this form with you at your next schedule visit.

 

Patient Form (Adobe PDF) - Use this form to provide us information about your child.
 

Financial Policy (Adobe PDF) - Use this form to Authorize Medical Benefit payments to be made directly to Georgetown Pediatrics.
 

Privacy Policy Practices (Adobe PDF) - This notice describes how medical information about you may be used and disclosed and how you can access this information - please review it carefully.
 
Medical Records Release (IN) (Adobe PDF) - Use this form to allow us to receive your medical records from another facility.
 
Medical Records Release (OUT) (Adobe PDF) - Use this form if you plan on having another facility retain your records with us.
 
KHSAA Sports Physical Form (Adobe PDF) - Kentucky High School Athletic Association Sports Physical Form. Use this form if you will need a student athlete physical.