APPLICATIONS AND FORMS

New patient registration

Patient History/First Visit

Lead and TB questionnaire

 Patient acknowledgement of privacy practices

Authorization for Request of Health Information from Previous Office (incoming)

Authorization for Release of Health Information (outgoing)

Gardasil Information

NC Health Choice Information/Application 

NC Health Choice Information/Application (Spanish)

DON'T FORGET TO FILL OUT YOUR AGES & STAGES QUESTIONNAIRE FOR EACH WELL CHECK (6 MONTHS - 5 YEARS)

Breastfeeding Self Assessment

ADHD Evaluation

RSV Prophylaxis Screening

Parent Consent Form

You will need Adobe® Acrobat Reader to view and fill out forms. If you do not have it, you can quickly download it FREE at http://www.adobe.com/products/acrobat/readstep2.html

 If you already have the Reader. Follow the instructions below.

 1. Click the link for the form you need.
 2. If you are asked whether you wish to save the form or open it, choose "open file from its current location," and click "OK."
 3. When the form opens place the cursor over a field that needs to be filled out. You may type directly onto the form.
 4. Using the tab key or your mouse you may navigate around the form filling in the required information.
 5. When you are finished filling out the form, print it and be sure to bring it with you to your office visit.

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