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©Children’s Pediatric Center East Main • 391 E Main St • The Historic Hawkins BuildingCanton Georgia 30114 • 770.720.MYMD (6963) • 770.720.6965 (FAX) • happyhealthy.com

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www.childrenspediatrics.com770.720.MYMD (6963)

Michael G. Anderson, MD, FAAP Stephanie H. Anderson, ND, RN, CS

NEW BABY PATIENT

Child: Last Name: ___________________________ First Name: _______________________ MI: ________________D.O.B.: _____/_____/_____ Sex: _______ Primary Language: ______________________________________

Ethnicity: Hispanic / Non-Hispanic / Unknown Race: Asian / Black / White /Unknown Mailing Address: _________________________________________________________________________________

(Street or PO Box) (City) (State & Zip) Home Phone: (________) ___________ - ______________Cell Phone: (________) ___________ - ______________Primary Caregiver: _______________________________________________________________________________Who lives at this household? ______________________________________________________________________

(Please note, this information is being requested to improve intake of your child’s Social History.)

Insurance Information Primary Policy: Policy Holder’s Name: _______________________________________________________________ Policy Holder’s Birth Date: ___________________ Policy Holder’s Sex: Male / FemaleInsurance Carrier: _______________________________ Policy ID#: ________________________________________Group #:____________________________ Secondary Policy: Policy Holder’s Name: _____________________________________________________________ Policy Holder’s Birth Date: ________________________________ Policy Holder’s SSN: ________-______-________Insurance Carrier: __________________________________________ Policy ID#: ______________________________Group #:____________________________

Guardian InformationGuardian 1: Name: ______________________________________________________ Date of Birth: ___ / ___ / ___ Lives with patient? Yes / No If no, please list primary phone number: ______________________________________Is this a cell phone? Yes / No Guardian’s Address: ___________________________________________________Relation to Patient: _________________________________ Biological Relation to Patient: ______________________

(Please note, this information is being requested to improve intake of your child’s Family Medical History.) Work Phone: ( ____ ) ______ - ___________ Cell Phone: ( ____ ) ______ - ___________Preferred Email: ________________________________________________ Home email / Work email (please circle)

How would this contact ideally prefer to be contacted regarding (circle one):Medical Issues: Home Phone / Work Phone / Cell Phone / Email Appointment Reminders: Home Phone / Cell Phone / Email Recall Notices: Home Address / Home Phone / Work Phone / Cell Phone / EmailPatient Portal Notifications: Cell Phone / Email

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Guardian 2: Name: ______________________________________________________ Date of Birth: ___ / ___ / ___ Lives with patient? Yes / No If no, please list primary phone number: ______________________________________Is this a cell phone? Yes / No Guardian’s Address: ___________________________________________________Relation to Patient: _________________________________ Biological Relation to Patient: ______________________

(Please note, this information is being requested to improve intake of your child’s Family Medical History.) Work Phone: ( ____ ) ______ - ___________ Cell Phone: ( ____ ) ______ - ___________Preferred Email: ________________________________________________ Home email / Work email (please circle)

How would this contact ideally prefer to be contacted regarding (circle one):Medical Issues: Home Phone / Work Phone / Cell Phone / Email Appointment Reminders: Home Phone / Cell Phone / Email Recall Notices: Home Address / Home Phone / Work Phone / Cell Phone / EmailPatient Portal Notifications: Cell Phone / Email

Emergency Contacts, other than parents: * In the event that the parent/guardian cannot bring child to the appointment, the following individuals will be allowed to bring.1: ___________________________ Relationship ____________________________ Phone: ( ___ ) _____ - _________2: ___________________________ Relationship ____________________________ Phone: ( ___ ) _____ - _________3: ___________________________ Relationship ____________________________ Phone: ( ___ ) _____ - _________4: ___________________________ Relationship ____________________________ Phone: ( ___ ) _____ - _________

Additional Contact Questions:Who should receive billing statements? ________________________________________________________________ May all contacts have access to the patient’s records electronically? Yes / No If no, list who may have access _______________________________________________________________________

** If parents are divorced or separated please fill out this section:Who has custody? ________________________________________________________________________________Are there any legal restrictions that would restrict the non-custodial parent from consenting to medical treatment for the child or from obtaining information about the child’s medical treatment? Yes / No

If yes, please explain and provide a copy of any legal paperwork that supports this restriction. _____________________ _________________________________________________________________________________________ _________________________________________________________________________________________

Signature _______________________________ Relationship to Patient _______________________ Date _________

Guardian Information(NEW PATIENT of 2)


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Patient Name: ____________________________________ Date of Birth: ______________ Date: _____________

New Baby History Form

Maternal/ Pregnancy History: Blood Type: O+ O- A+ A- B+ B- AB+ AB-Hep B surface Antigen: Positive Negative Unknown Do parents live in same household? Y or NRPR/ VDRL: Positive Negative Unknown Mothers Maiden Name _________________________Rubella: Immune Not Immune Unknown Mother Ethnicity ______________________________HIV Status: Positive Negative Unknown Father Ethnicity ______________________________Group B Strep: Positive Negative Unknown Amino/ CVS Testing: Not Done Normal

Birth Information:Birth Date: __________________________ Birthplace: __________________________________________________Birth Time: _________________________ County: _________________ City: ___________________ State _______Part of a multiple birth: Y N _________ Birth Measurements: Gestational Age: ____________________ Length: _____________ (inches) Weight: ______________ (pounds) Type of Delivery: _____________________ Head Circumference: ___________________________________ (inches)Feeding: ___________________________ Discharge Date: ______________________________________________Blood Type: O+ O- A+ A- B+ B- AB+ AB- If Adopted, at what age was child adopted? _________________________ Hearing Screening: Pass Fail Refer Right Refer Left Refer Bilateral

Past Medical History: If yes, please explain: (If it does not apply put N/A)Y N Newborn Screen reviewed ___________________________________________Y N Resuscitation at delivery ___________________________________________Y N Preterm infant ___________________________________________Y N Refusal of Vitamin K and/or eye Prophylaxis ___________________________________________Y N Feeding: Breastmilk ___________________________________________Y N Feeding: Formula ___________________________________________Y N Hypoglycemia ___________________________________________Y N Hypothermia ___________________________________________ Y N Sepsis Screening Labs ___________________________________________Y N Transcutaneous bilirubin (tcB) ___________________________________________Y N Jaundice ___________________________________________Y N Circumcision ___________________________________________Y N Delayed Passage of Meconium ___________________________________________Y N Murmur ___________________________________________Y N Respiratory Problems (TTN/RDS) ___________________________________________Y N Oxygen ___________________________________________ Y N Assisted Ventilation ___________________________________________Y N Antibiotics ___________________________________________Y N Apnea ___________________________________________Y N Head Ultrasound ___________________________________________Y N Ophthalmologic exam ___________________________________________


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Maternal Perinatal History:Y N Assisted Conception ___________________________________________Y N High risk pregnancy ___________________________________________Y N Amniocentesis/ CVS ___________________________________________Y N Absence of prenatal care ___________________________________________Y N Maternal use of alcohol/ tobacco/ drugs ___________________________________________Y N Problems with maternal health ___________________________________________Y N Problems with fetus ___________________________________________Y N Prolonged rupture of membranes ___________________________________________Y N Other Medications during labor/ Antibiotics ___________________________________________Y N Induction of labor ___________________________________________Y N Delivery by C-section ___________________________________________Y N Other Significant Problems ___________________________________________Y N Meconium at delivery ___________________________________________ Social History:Y N Lives with an intact family ___________________________________________Y N Non-Intact custody status ___________________________________________Y N Visitation status of non-custodial parent(s) ___________________________________________Y N Siblings ___________________________________________Y N Pets (Dogs or Cats) ___________________________________________Y N Turtle Pet at home ___________________________________________Y N Uses car restraints with age appropriate car seat or Booster, shoulder harness and lap belt with child in Rear seat, away from airbag system. ___________________________________________Y N Smokers in the home ___________________________________________

ADDITIONAL COMMENTS: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Signature _______________________________ Relationship to Patient _______________________ Date _________

Patient Name: ____________________________________ Date of Birth: ______________ Date: _____________

New Baby History(Page 2 of 2)


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www.childrenspediatrics.com770.720.MYMD (6963)

Michael G. Anderson, MD, FAAP Stephanie H. Anderson, ND, RN, CS

WELL VISIT SCHEDULE

Age: What to expect at visit:

Initial Newborn Visit New patient paperwork/ development sheet1 or 2 week Visit Development Sheet1 month visit Development Sheet2 month visit Development Sheet/ vaccines4 month visit Development Sheet/ vaccines6 month visit Development Sheet/ vaccines9 month visit Development Sheet/ ASQ 12 month visit Development Sheet/ vaccines/ CBC & Lead Labs15 month visit Development Sheet18 month visit Development Sheet/ ASQ/ M-Chat Sheet24 month visit Development Sheet/ M-Chat/ Vaccines/ CBC & Lead Labs30 month visit Development Sheet/ ASQ3- 10 year visit Development Sheet/ PAQ/ PPE/ Hearing & Vision Screen (Vaccines at 4 year visit)11-18 year visit Development Sheet/ PAQ/ PPE/ Y-PSC Form/ Hearing & Vision Screening/ (Vaccines at 11 year visit)

After your child turns 3, well visits will only be conducted once every 12 months and day.

Vaccine schedule could vary for each individual child. Above ages are the typical ages in which a child receives vaccines, but may not apply to each child.

At the Initial newborn visit, each parent will receive a book: “Your Baby’s First Year.” Chapter 27: “Immunizations,” is very informative of the vaccines that your child is offered and explains the benefits of each vaccine.

Explanation of Forms Listed Above:

Development Sheet: Development Information pertaining to current ageASQ: Ages and Stages QuestionnaireM-Chat: Modified Checklist for Autism in ToddlersPAQ: Information about Nutrition and Physical Activity PPE: Pre-participation Physical Evaluation Form (also used for sports physical)Y-PSC: Pediatric Symptom Checklist


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The Importance of One-On-One Time for Every Child

Growing Confidence & Better BehaviorMoms, Dads and grandparents know how “one-on-one” time with each child creates cherished memories and builds emotional maturity for later in life. Also, such a child may feel less sibling rivalry and act-out less for attention. Dr. A shares how his grandmother brought him to the dentist or pediatrician without four brothers in tow. Afterwards grandma treated for lunch or ice cream. Warm memories of his grandma are the result.

Better Communication for Serious MattersIn addition, beyond the above legacy, one-on-one time for each child has other immediate benefits. Families agree that a visit to the doctor requires them to communicate important concerns from the family to the doctor, and then after the diagnosis, this and any treatments must be communicated back to the family. All qualifies as serious matters. More so, with a medical procedure (such as an injection or vaccine) a family must focus on the one child, and first be certain all is fully understood and totally appropriate for this child to their full satisfaction before starting the procedure. When more than one school-age child is in the exam room together (those who are too young to self-maintain, typically between 2 to 10 years) then these may begin poking, pinching or teasing each other. Then the cry “M…O…M… he/she keeps bothering me, tell him to stop!” How can dragging the focus away from such serious matters at hand be permitted? Would a responsible pediatric team allow such distractions away from the one child? The responsible doctor must make certain the exam and visit, for each individual child, has the environment to ensure a careful evaluation for signs of a child’s wellness or illness.

Supporting your Children and FamilyWe understand that these days a family has multiple obligations within a compressed daily schedule. Their employers may demand they produce more value in less time. Scheduling one-on-one time, even to visit the pediatrician, may become a family challenge. In support of your family we are ready to provide a letter, note, or a phone call to an employer for a family as requested. We strive to understand and will make reasonable accommodations while keeping the standards for quality pediatric care and patient safety.

Every child requires individual focused attention for their medical encounter. If we agree together for your child’s pediatric care, then please read the following and sign below. The doctor encourages that when two or more children (who are too young to self-maintain, typically between 2 yrs to 10 yrs) are both scheduled for an exam the same day, then:(1) Please consider arriving with at least two (2) responsible adults to attend with the children’s pediatric visits.

(2) Also with two (2) or more adults then each child will have their own time, in their own separate exam room.

(3) Also helpful if three (3) or more family members arrive (who are not scheduled to visit with the doctor) then if some of these may wait in the family area with the chaperone until each child’s visit is completed to support the best care.

(4) On the exception when only one family member must accompany more than one child on the same day, then the two or more visits will be scheduled separately so each has their own scheduled office-time, of course other families may have scheduled before with visits that must be seen in-between the children from your family. Excepting for an urgency of medical need, each child may complete their own office visit, from taking vitals measurements, donning a medical gown, diagnosis to discharge, before starting the next child’s visit. By encountering each child “one-at-a-time” then all have their own visit, as if they had arrived separately.

(5) Because some families must schedule more than one child on the same day, without an additional chaperone, then as we support all our families, please plan for some extra visit time at the doctor’s office. For example, a child’s visit may require up to 60 minutes from check-in to check-out. More children, each with their own separate visits, may require an additional 30 minutes each. By addition, two children, scheduled for successive exams on the same day may require families to plan for 90 minutes total, then three children (2) hours, and so forth.

We strive to understand and will support a family’s circumstance as best as we are able. Our purpose here is not some rigid rule, but to deliver safe and quality pediatric experience for every family all the time. Our hope remains that with this plain explanation families may accept that our duty allows for only a limited amount of flexibility from the model of one-at-a-time as the best quality of care for a child.

Having read the above and asked all my questions, the Undersigned asks the pediatric center to provide care as explained.

__________________________________ ________________________________________ _____________Name of Child (or Children) receiving care Signature of Medically Responsible Family Person Date

@ 2015 LitConUS LLD Intellectual Property. No copying or any type reproduction permitted without a written license from LitConUS LTD.


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From: Doc Mike & Stephanie

Re: Can Waiting Mean Something Worthwhile?

Infants and children demand compulsive medical attention. They have subtle symptoms and often Pediatricians uncover illness during even wellness appointments. The traditions of pediatrics teach that every child deserves individualized and compulsive care for all their unpredictable needs. We honor these traditions as we strive to our goal … “give perfect care to every child every time” as the signs read in each exam room.

The unpredictable nature of pediatrics forces doctors to choose either compulsive care or a predictable schedule, but not both. Years ago when families had less intense life-styles they waited to see only their own doctors and accepted that same-day, sick appointments (or any on Mondays, Fridays, or after school) required more waiting. We keep the traditions of pediatrics including individualized and compulsive care, guaranteeing same-day sick appointments, and the attendant waiting.

A medical school professor once instructed his students …

“A good reason may be accepted if offered in advance; however, when given after the fact it sounds like an excuse.”

We intend that this clear note regarding expected waiting, especially for sick-appointments, may be accepted by families, as we intend no disrespect to our patients. Pardon us and know your waiting patiently means something very worthwhile to many … those who are also sick and all of us striving to serve every family perfectly. Thank you for the trust and privilege.

Doc Mike & Steph


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Medical Home Children’s Specialty Care and ServicesThank you for the trust and privilege to care for your child. As we welcome you to The Children’s Pediatrics Center East Main Street, we wish your family to know that our goal is to serve as your Family’s available and familiar MEDICAL HOME for all your Family’s pediatric needs. For the minimum benefit, we ask your Family to allow us to be of service and guide your child’s Pediatric Care after hours. This is the Good News.

Same-Day Sick Appointments: We offer same-day sick appointments, meaning we may schedule your child for an appointment on the very same day that you call, especially when you call in the morning, to offer the most choices for appointment times. Below you may read our usual offerings for in-office appointments.

After Hours: We are ready. Any time, day or night, weekends and holidays, as one of the Children’s Pediatrics Center Families, you will always have access to your pediatric specialist for all medical concerns and issues.

Day of Week Available by telephone using live-person answering service recorded time/date/number and voice recording, with live-patch call to physician after-hours.

Regular Schedule for providing in-office service

Monday 24 hrs / day : 00:00 AM to 23:59 PM 8:30 AM to 17:00 PM

Tuesday 24 hrs / day : 00:00 AM to 23:59 PM 8:30 AM to 17:00 PM

Wednesday 24 hrs / day : 00:00 AM to 23:59 PM 8:30 AM to 17:00 PM

Thursday 24 hrs / day : 00:00 AM to 23:59 PM 8:30 AM to 17:00 PM

Friday 24 hrs / day : 00:00 AM to 23:59 PM 8:30 AM to 17:00 PM

Saturday & Sunday 24 hrs / day : 00:00 AM to 23:59 PM exceptional, no advance schedule

The Children’s Pediatrics Center is always ready and never more than a phonecall away. We are standing-by with specially-trained, live-person telephone operators waiting to receive your Family’s telephone call day or night. 24 hours per day, 365 Days per year. Other than 911, the only number you need to remember is 770-720-MYMD (6963). When you call, expect only a friendly voice of a real, living person, we don’t use machines to talk to our Families. When calling in the evening, once the operator notes important information, you may be directly-patched to your pediatric specialist while you wait.

An Original Medical Home: The reason Children’s Pediatrics East Main designed and selected its location on Main Street, and renovated a 100 year’ old home is because it is from where Dr. Hawkins historically practiced. Our goal is to serve your family and child, and to be available to assist with all your child’s pediatric care needs no matter when they occur. We wish you to know that we are the home or hub for all you pediatric care and assist in planning care needs around the clock, all year long.

Prepared for Weather Emergencies: Never worry, your Pediatric Center is be powered-up by a GE stand-by generator keeping us prepared with our own electrical power generator to keep going strong even when a weather emergency strikes.

Only Pediatric Specialty: Never charge off to a “Quickie” clinic or any other place that has no pediatric specialist. Call your Medical Home first so we may help, and we have pre-arranged and credentialed Pediatric Centers to serve your child. (below)

Cherokee County & South Cherokee County & South Pickens County &NorthChildren’s Healthcare of Atlanta Wellstar Pediatric Center Erlanger Children’s Hospital

Town Center Urgent Care 625 Big Shanty Rd NW Kennesaw, GA 30144

Barrett Parkway Center 1180 Barrett Parkway Kennesaw GA, 30144

Urgent Care 910 Blackford Street

Chattanooga, TN 37403

(404) 785-8010 (770) 793-5000 (423) 778-9107 Emergency: When it’s 911 then call 911 first and then call us afterward: In every case we may have important information to share with the emergency doctors regarding your child’s care. We have been pre-credentialed with Pediatric-Specific facilities:

Pediatric Specific Emergency Services Affiliated and Credentialed with CPCN-LTDCherokee County & South Pickens & Cherokee County Gilmer County &North

Children’s Healthcare of Atlanta Wellstar Kennestone Hospital Erlanger Children’s Hospital

Pediatric Emergency 1001 Johnson Ferry Rd NE

Atlanta, GA 30342

Pediatric Emergency 677 Church Street Marietta, GA 30060

Pediatric Emergency 910 Blackford Street

Chattanooga, TN 37403

(404) 785-5252 (770) 793-5000 (423) 778-6101


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Retail-Based Clinic. Policy Work Group American Academy of Pediatrics

AAP Principles Concerning Retail-Based Clinics DEDICATED TO THE HEALTH OF ALL CHILDRENTM

Policy Statement

The American Academy of Pediatrics (AAP) opposes retail-based clinics (RBCs) as an appropriate source of medical care for infants, children, and adolescents and strongly discourages their use, because the AAP is committed to the medical home model. The medical home model provides accessible, family- centered, comprehensive, continuous, coordinated,compassionate, and culturally effective care for which the pediatrician and the family share responsibility. 1 Given that the RBC is not a medical home model, the AAP is partic-ularly concerned with the effects of the following attributes of an RBC on health care for children and adolescents:

Seeing children with “minor” conditions as will often be the case in an RBC, is misleading and problematic. Many pediatricians use the opportunity of seeing the child for something minor to address issues in the family, discuss any problems with obesity or mental health issues, catch up on immunizations, identify undetected illness, and continue strengthening the relationship with the child and family. These visits are important and provide an opportunity to work with patients and families to deal with a variety of other issues that the RBC is not a medical home model; the AAP is particularly concerned with the effects of the following attributes for an RBC on health care for children and adolescents:

• Fragmentation of care• The possible effects on a quality of care• Provision of episodic care to children with health care needs and chronic diseases, who may not be really identifiable • Lack of access to and maintenance of a complete, accessible, central health record that contains all pertinent patient information.

The use of tests for the purpose of diagnosis without proper follow-up• The possible public health issues that could occur when patients with contagious diseases are in a commercial, retail environment

with little or no insolation (eg, fevers, rashes, mumps, measles, strep throat, ect).• Seeing children with “minor” conditions as will often be the case in an RBC, is misleading and problematic. Many pediatricians use

the opportunity of seeing the child for something minor to address issues in the family, discuss any problems with obesity or mental health issues, catch up on immunizations, identify undetected illness, and continue strengthening the relationship with the child and the family. These visits are important and provide an opportunity to work with patients and families to deal with a variety of other issues.

The AAP

1. Supporting the Medical Home Model: RBCs should support the medical home model by referring the patient back to the pediatri-cian or other primary care physician for all future care. In the event that the patient does not have a relationship with a pediatrician or primary care physician, RBCs should have the means to assist the family in establishing contact with one another in a medical home. Third party payers are encouraged to provide appropriate incentives to plan members to access the medial home as the best practice model for pediatric care.

2. Communication: The AAP recommends that the RBCs promptly communicate with the patient’s pediatrician or other primary care within 24 hours of the visit. At a minimum, the following information should be included: patient’s name, date of birth, at least 2 additional pieces of identifying information (eg, parents’ name and/or address) reason for visit diagnosis and AAP Principles Con-cerning Retail Based Clinics, continued disposition findings, laboratory results (if any) and an indication as to whether any follow up is needed.

3. Using Evidence-Based Medicine: The AAP recommends that all those providing care to children follow all AAP clinical guidelines as well as those guidelines developed by other medical organizations that have the support and endorsement of the AAP. RBCs should be required to participate in ongoing quality-improvement and quality-assurance processes as required of pediatric and other primary care practices. RBCs must meet all requirements related to quality assurance and ensure full compliance with state licensure requirements for oversight or collaborate protocols relative to scope of practice.

4. Contagious Diseases: By providing medical care to individuals in a retail-based setting. RBCs must take the necessary precautions to prevent the spread of contagious diseases. Although the RBC may have policies that limit the scope of services, this may not prevent individuals with contagious diseases from seeking care at RBCs. This presents a potential public health hazard to retail staff and customers who may come in contact with a contagious individual. RBCs should be subject to and comply with all health care facility standards (eg, hygiene, safety, regulations of the Occupational Safety and Health Administration, policies and proce-dures for children with communicable diseases, ect).

5. Financial Incentives: The AAP is opposed to waiving or lowering co-pays or offering financial incentives for visits to RBCs in lieu of visits to pediatricians or other primary care physicians’ offices. The AAP believes the medical home model is the optimal standard care, and RBCs are not medical AAP Principles Concerning Retail Based Clinics, continued homes. Payer incentives should not promote fragmentation of care but should instead recognize and reward systems of care that promote continuous, coordinated, and comprehensive care.

RETAIL-BASED CLINIC POLICY WORK GROUPRobert M. Corwin, MD Anne B. Francis, MDThomas K. Mclerny, MD

Joseph W. Ponzi, MDMark S. Reuben, MDRobert D. Walker, MD

Steven E. Wegner, MD, JDKyle Yasuda, MD Heather Fitzpatrick, MPH

Louis A. Terranova, MHALinda Walsh, MABTeri Salus, MPA, CPC

REFERENCE: American Academy of Pediatrics, Medical Home Initiatives for Children with Special Needs Project Advisory Committee. The medical home. PEDIATRICS Vol. 127 No., 3. March 2011, pp. e857 (doi:10:1542/peds.2010-3671)

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