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Georgetown Pediatrics Office Forms

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

Patient Registration 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 want to release your records to another facility.


KHSAA High School Sports Physical Form (Adobe PDF) - Kentucky High School Athletic Association Sports Physical Form. Use this form if you will need a high school student athlete physical.


KHSAA Middle School Sports Physical Form (Adobe PDF) - Kentucky Middle School Athletic Association Sports Physical Form. Use this form if you will need a middle school student athlete physical.

Georgetown Pediatrics, P.S.C. - Pediatrician in Lexington, Georgetown, Scott County, Kentucky, Nicholasville, 40324, 40511, 40508, 40340, 40356, 40502, 40503, 40504, 40506. Fayette County, Winchester, Scott County, Jessamine County, Kentucky childrens doctor. Child doctor. Immunizations. Separate Well Visit and Sick Visit waiting rooms available. KHSAA Kentucky Sports Physical, Georgetown, Fayette, Jessamine County Kentucky. Kids Doctors serving Georgetown Kentucky and Surrounding Areas.Georgetown Pediatrics Office features 2 separate entrances for Well and Sick Children.