Forms and Policies
Our Mission Statement
Our Practice
Our Practice Logo
Doctor Profiles
Our Advanced Care Team
PCMH Obligations
Patient Portal Login
Making an appointment
24 Hour On-Call Coverage
Insurance Coverages
Forms and Policies
Make Online Payments
Recommended Links
Below are our office policies and forms that can be reviewed and downloaded for your convenience.   You can save time and fill these out prior to your appointments.

New Patient Forms


These forms will be given at your baby's first visit.  You can download them here and save time at their first visit.

Patient Information and Demographics

Consent for Treatment Form

Newborn Insurance Policy

Appointment Policy

Prescription Medication Consent

Financial Policy

Authorization For Release

HIPPA Signature Form

HIPPA Policy for Reviewing (No need to download)

Child and Teenager Questionnaires


6 - 10 Year Pediatric Symptom Checklist

11 - 17 Year Questionaire (For the Adolescent to Answer)

2018-2019 School Athletic Participation Form

Please note, these files will open in Microsoft Word format

The Pediatric Center *1914 Glen Meade Rd *  Wilmington, NC  *  (910) 762-2651