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.

A. Office Policy Packet

B. New Adult Patient Forms Packet (6, 4, 3, 2, 1)

C. New Pediatric Patient Forms Packet (7, 5, 22, 3, 2, 1)

1. Notice of Privacy Practices

2. Consent to Use or Disclose Information

3. Practice Financial Policies

4. Adult Health History

5. Pediatric Health History

6. Adult Registration

7. Pediatric Registration

8. Medical Records Release Form

9. Medicare Annual Wellness Visit

10. NC Childcare / Daycare Medical Form

11. Parent Evaluation Form

12. Teacher Evaluation Form

13. Parent Follow Up

14. Teacher Follow Up

15. Request For Restriction Of Uses And Disclosure Of PHI

16. Preventative Services Coverage Notice

17. Payment Plan Agreement

18. HIPAA - Disclosure Consent Form

19. Disclosure and Consent Form

20. Advanced Beneficiary Notice Of Non-Coverage

21. Minor Consent To Treat

22. Vaccination Policy