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Patient Forms

For your convenience, we have made our patient forms available for download. If you wish, you may complete the forms prior to your initial appointment and bring them with you to your appointment.

All forms below are required for your appointment.


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EarWell Ear Deformity Correction in Atlanta

Medical Record Release

Please be advised that Atlanta Plastic & Reconstructive Specialists require a $25.00 fee for patient requests of their medical records, unless they are being sent to another medical facility. Payment is due prior to the release of any records. Please note that it takes approximately 7 – 10 business days to process medical records requests.

To have a copy of your medical records sent to another facility or to obtain a copy for personal purposes, please complete the following steps.

  1.  Download the Authorization for the Release of Protected Health Information form
  2. Complete, sign and date the Medical Release Authorization form.
  3. Please fax to the numbers provided below or mail the completed and signed Medical Release Authorization
    form to Atlanta Plastic & Reconstructive Specialists at either of these addresses:

5673 Peachtree Dunwoody Rd NE #870

Atlanta GA, 30342

Fx: 404-255-2276

105 Collier Rd Suite #1040

Atlanta, GA 30309

Fx: 404-343-0496

Family and Medical Leave Act (FMLA)

Our policy regarding Family and Medical Leave  Act (FMLA) and Disability forms must be completed by our nurse, which requires a fee. Please be aware of these fees, as they are not covered by health insurance and are solely the responsibility of the patient.

Please allow 7 – 10 business days for completion
– One Page – $10.00
– Two or more pages – $25.00

For easy viewing and printing, Patient Forms are presented in Adobe format (.pdf). For a free copy of this program, click here and follow the instructions.

If your insurance doesn’t cover all the costs for the procedure you want and need, where do you turn? CareCredit, a GE Money Company, gives you convenient payment options so you can get the procedure you want, when you want it.

You can apply over the phone by calling (800) 677-0718 between 5:00 a.m. – 7:00 p.m or online by visiting:

Payment Calculator