Medical Forms

For your convenience, forms may be completed prior to your appointment. All patients please complete Registration, Health Questionnaire and Office Policies. Our care will be most effective for you if you provide a comprehensive medical history, including any care obtained outside of our practice. This includes current medications, allergies, visits to specialists, past medical history, health status, behavior health care, recent test results, self-care information and records from recent hospitalizations, specialist care, or emergency department visits.

male-doctor-writing-on-medical-document-34803387

New Patient Forms

Administrative Forms – You may complete these forms through our Healow Check-In process

Medical Forms – Please download these forms from the links below to complete and bring with you to your appointment.

Adult Health History or Pediatric Health History (under age 18)
Adult Registration or Pediatric Registration (under age 18)

Medical Records Use/Release Form

Medical Records Release – This form must be signed by the patient or responsible party.

Medicare Patients Over Age 65

School & Sports Physical Forms

Request For Medical/Physical Form Completion
NC Childcare / Daycare Medical Form
NC Public Schools Health Assessment Form
NC High School Athletic Association Physical Examination Form
NC Wake County Public Schools Middle School Athletics Form

ADD and ADHD Screening Forms

First visit for ADHD evaluation:

Follow up ADHD visits:

Referrals

Referral Form

NC HealthConnex HIE

Our office participates in the NC Health Information Exchange (HIE). See below for more details about how the HIE benefits you or to opt out.