This page has changed! We have now grouped the required forms depending on the age of establishing patients. Look below and find your appropriate group and print ALL forms that are listed except for the HIPPA- Notice of Privacy Practices. That is there for you to print if you would like but is not required for the initial visit to our office. Please let our staff know if you need any help and we will gladly assist you!
Salisbury Pediatrics Required Forms for Newborns
Authorization for Release of Information (needs to be filled out for ANYONE other than a parent to bring your child to an appointment)
Medical History Information Sheet
Acknowledgement of Receipt: Notice of Privacy Practices
Newborn Financial Agreement Form
Consent for Treatment & Agreement to Pay
Medical Records Release Form (for patients WITHOUT a Portal account)
HIPPA- Notice of Privacy Practices (Does not have to be printed but is available)
Salisbury Pediatrics Required Forms for New Patients Under 18 Years Old
Authorization for Release of Information (needs to be filled out for ANYONE other than a parent to bring your child to an appointment)
Medical History Information Sheet
Acknowledgement of Receipt: Notice of Privacy Practices
Consent for Treatment & Agreement to Pay
HIPAA- Notice of Privacy Practices (Does not have to be printed but is available)
Salisbury Pediatrics Required Forms for New Patients 18 Years Old & Up
Authorization for Release of Information (needs to be filled out for ANYONE other than a parent to bring your child to an appointment)
Medical History Information Sheet
Acknowledgement of Receipt: Notice of Privacy Practices
Consent for Treatment & Agreement to Pay
HIPAA- Notice of Privacy Practices (Does not have to be printed but is available)
Other Forms (Required by schools, etc.)
North Carolina Health Assessment Transmittal Form (ALL students enrolling in a NC Public school for the first time will need this form)
North Carolina High School Athletic Participation Form
Rowan County Schools- Physician's Medication Authorization Form (REQUIRED for all medications, prescription and non-prescription)
Rowan County Schools- Diet Order Form (REQUIRED for all students who need a modified or restricted diet)
WIC Program- Medical Documentation Form (Birth - 12 months old)
WIC Program- Medical Documentation Form (12 months old & up)
If you need a medical form completed, we will be glad to assist you. We require 2 business days to complete forms and the child must have had a physical within a year, usually. There is a charge of $20.00 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.
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.
