Esophageal Institute of Atlanta, C. Daniel Smith, MD, FACS logo for print
2045 Peachtree Road NE, Suite 310, Atlanta, Georgia 30309
Phone: 404-445-7787 • Fax: 404-445-8404

ESOPHAGEAL
INSTITUTE
OF ATLANTA

Patient Center

Patient Forms

Complete Forms Packet

Please print and complete the forms before your appointment and fax them to our office at 404-445-8404 or bring them with you to your appointment.

Individual Forms

If you need an individual form from the Patient Forms Packet, please choose the form below.

Additional Forms


Office Policies

Complete Financial Policy

Appointment Cancellation

A 24-hour cancellation notice is required for office visits. If you are unable to make your scheduled appointment and do not provide a 24 hour notice to cancel a $30.00 fee will be applied to your account.

Medical Records

A request for medical records must be made in writing to our office. Upon receiving the request, our office will process the records request within a 72-hour period. The fee for Medical Records is $15.00 and is due and payable at the time of the request.

Forms Requests

Requests for the completion of the medical documents such as Disability leave, Cancer, Life or other health insurance forms, Employment exams, School physicals exams, Family Medical Leave (FMLA) or other documents required by a third party other than your insurance carrier will have a $25.00 fee due at the time of request for said documents. Upon receiving the request our office will process the records request within a 72- hour period.

Related Links

Convenient Atlanta Office

Our office is located on Peachtree Road in the heart of Buckhead conveniently located near Piedmont Atlanta Hospital.

Office building for the office of Esophageal Institute of Atlanta, C. Daniel Smith, MD, FACS