Referral Request - Pedatric Associates of Lawrencevill

- Use PAL's online resources for new patients to preregister, make appointments, and familiarize yourself your child's immunization and well-check schedule.
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- PAL’s office is open Monday through Friday, 8am to 5pm, and most Saturday mornings. We see patients by appointment only for health checks, and consultations. Please call to make an appointment for sick visits.
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- Please allow our staff 72 hours to respond to your online inquiry. If you experience difficulty completing any forms, contact PAL by telephone.
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- The appearance of external hyperlinks does not constitute an endorsement by PAL of the linked web sites, or the information, products or services contained therein.
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Referral Request

Referral Process
Please allow our staff 1 to 3 business days to process your online preregistration. If you experience difficulty completing this form, or would rathercontact PAL by telephone, please call 770.277.6725.contact PAL

Please complete and submit the following form and one of PAL's office staff will respond to your inquiry as soon as possible.

Fields marked with an asterisk (*) are required. All other fields are optional.

Referral Request From PAL

Parent's Full Name:*

Child's Full Name:*

Child's Date of Birth:*

Phone 1:*

Phone 1 Type:*

Phone 2:

Phone 2 Type:

Contact Email:*

Contact Preference:*

Respond by Email
Respond by Telephone

Insurance Company:*

Policy Number:*

Type of Specialist:*

Specialist Name:*

Appointment Date:*

Location of Appointment:*

Specialist's Fax number:*

Reason for Appointment:*

For Medicaid referrals, please provide the doctor's reference number:

Doctor's REF number:

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