Patient Forms

If you need a medical form completed for school or camp, we will be glad to assist you.  We require 2 business days to complete forms and the child must have had a physical with in a year, usually.  There is a charge of $10.00 for completing forms, which is due when we receive the form.  You may pick up the completed form at our office.  If you prefer to have the form mailed to you, provide a self addressed stamped envelope.  We will not fax completed forms.

Most schools require a doctor’s authorization to administer medication during school hours.  This includes over-the-counter medications.  If your child takes medication on a regular basis during school hours, please request a medical authorization form from your school prior to the first day of class.  Your child must be up-to-date on check-ups and immunizations in order for a form to be completed.

Here is a list of some of the more common forms our patients need filled out.

WIC Program Prescription
NOTE: There are two pages to this form.  Please fill out only page one for for babies birth through 12 month.  Fill out only page two if your child is older than 12 months.

High School Sports Participation Examination Form

NC Kindergarten Health Assessment Report

Medical Form Request

Medical Records Request

Secure Email Release

Children’s Medical Report Form

Guilford County Schools Authorization for Medication Form

Here is a list of our office policies and patient forms:

Vaccination Policy

Self Pay Waiver

Policy Information Agreement

Notice of Privacy Practices

Missed Appointment Policy

Medicaid Policy

Financial Policy

Code of Kindness