The Pediatric Center of Stone Mountain, LLC
5405 - D Memorial Drive, Stone Mtn. GA 30083
Tel (404) 296-3800 Fax (404) 297-8753
www.the-pediatric-center.com
Edward M. Gotlieb, MD, FAAP, FSAM
Adolescent Medicine, Pediatrics
Laura Yedvobnick, PA
Pediatrics
Kathleen Allen, MA, LPC
Counseling
Jaquelin S. Gotlieb, MD, FAAP
Pediatrics
Lucinda Sellers, CPNP
Pediatrics
Margaret Duly, LCSW
Licensed Clinical Social Worker
Adolescent Privacy Statement Date:_________________
Patient Age Today is: _____
Parent:
I, ________________________________(parent or guardian), allow
_________________________________(patient), to enter a confidential patient-physician
relationship. I understand that he or she can make independent health care decisions
regarding medical care, medical tests and services, but that my input and involvement will be
encouraged.
__________________________(patient) has permission to schedule appointments, seek
treatment and receive confidential reports from the office. I further understand that various
laboratory tests may be necessary in medical protocols and accept responsibility for the
charges.
________________________parent/guardian _________________________physician
Patient:
I, ______________________(patient, am entering a confidential physician-
patient relationship with TPC and my physician, ________________________________. I will
make an effort to communicate with my parent(s) or guardian(s) about issues concerning my
health. I accept the personal responsibility of being honest and will follow the health care
recommendations my physician and I establish.
__________________________patient
___________________________physician