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Forms and Policies
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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

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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)

 
 
Ages & Stages Questionnaires

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These are the forms you will fill out at each well visit to track your child's development.   You can download them ahead of time to see if your child has met most of their milestones.  Bring this form in at their upcoming well visit.

4 Months Ages & Stages

6 Months Ages & Stages

9 Months Ages & Stages

12 Months Ages & Stages

15 Month Ages & Stages

18 Month Ages & Stages

M-CHAT (Autism screen for 18 months and 24 months)

24 Month Ages & Stages

30 Month Ages & Stages

3 Year Ages & Stages

4 Year Ages & Stages

5 Year Ages & Stages

6 - 10 Year Pediatric Symptom Checklist

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

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