We are happy to provide our office forms for convenient download on your home computer.
Please print and complete the forms below, and bring them with you to your child’s appointment.
NEW PATIENTS
- New Patient Forms (English)
- New Patient Forms (Español)
- HIPAA Notice of Privacy (English/Español)
- The privacy notice is for your information only. You do not need to bring this to your appointment.
- NCHealthConnex Opt-Out Form (English/Español)
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WELL CHILD CHECK SCREENING FORMS
For well checks ages 6-10 years:
- Pediatric Symptom Checklist
To be completed by parent
For well checks ages 11-14 years:
- Pediatric Symptom Checklist
To be completed by parent - Pediatric Symptom Checklist – Youth
To be completed by patient
For well checks ages 15-18 years:
- Pediatric Symptom Checklist
To be completed by parent - Pediatric Symptom Checklist – Youth
To be completed by patient
SCHOOL FORMS
- Kindergarten Health Assessment Form
To be completed by parent - Sports Physical Form
To be completed by parent - Flu Vaccine Form
For flu vaccine only visits, to be completed by parent