Print and fill out forms ahead of time for faster service at the health department.

presumptive medicaid app001.pdf
Adobe Acrobat document [1.4 MB]
Patient self-history form001.pdf
Adobe Acrobat document [1.3 MB]
Patient self-history form in Spanish
D-4 Spanish history form 07-12.pdf
Adobe Acrobat document [73.2 KB]

Dental Applications

Dental Application Forms for Barnesville Dental Clinic
Please print and fill out all forms completely.
Dental Packet Forms for Printing - Barne[...]
Adobe Acrobat document [315.3 KB]

Return completed application forms for the Barnesville Dental Clinic to the Lamar County Health Department.


118 Academy Drive

Barnesville, GA 30204

Fax: 770.358.1258

 

Return completed application forms for the Franklin Dental Clinic to the Heard County Health Department.

 

1191 Franklin Parkway

Franklin, GA 30217

Fax: 706.675.6795

 

Forms for providers

 

All Georgia physicians, laboratories, and other health care providers are required by law to report patients with specific diseases. Both lab-confirmed and clinical diagnoses are reportable within the time interval specified on the NOTIFIABLE DISEASE/CONDITION REPORTING poster. Reporting enables appropriate public health follow-up for your patients, helps identify outbreaks, and provides a better understanding of disease trends in Georgia.



Reporting of diseases may done through our web-based electronic disease reporting system, SendSS (State Electronic Notifiable Disease Surveillance System). You may also print the GEORGIA NOTIFIABLE DISEASE/CONDITION REPORT FORM below and fax it to our office at 706.845.4350.





GEORGIA NOTIFIABLE DISEASE/CONDITION REPORT FORM
Please fill out completely and fax to 706.845.4350.
notifiable report form.pdf
Adobe Acrobat document [604.9 KB]
Dental Application Forms for Franklin Dental Clinic
Please print and fill out all forms completely.
Dental Packet Forms for Printing - Frank[...]
Adobe Acrobat document [315.3 KB]