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Patient Forms
Following are the forms that we use for all patients with our office. The new patient forms can be downloaded and printed for
your convenience. Most items are in Adobe PDF format. If you do not have the Adobe Acrobat Reader software, click the link at
the bottom of the page to download it for free.
All new patients are asked to print and complete the forms marked with an ( * ).
| Form Name | Type |
| Patient History Form * - English |  |
| Patient History Form * - en Español | |
| Family Demographic Form * - English | |
| Family Demographic Form - en Español | |
| Lab Form - English | |
| Lab Form - en Español | |
| Online Appointment Request form - Well Child Checks ONLY |  |
| Online Prescription Refill Request | |
| Release of Private Health Information - English | |
| Release of Private Health Information - en Español | |
| Acknowledgement Form (HIPAA) - English | |
| Acknowledgement Form (HIPAA) - en Español | |
| Consent Form - English | |
| Consent Form - en Español | |
| Notice of Privacy Practices - English | |
| Notice of Privacy Practices - en Español | |
| Chat Form for Autism Screening - English | |
| Chat Form for Autism Screening - en Español | |
Our forms are provided in Adobe PDF format. You will need the Adobe Acrobat Reader to view the forms. Clicking the link below will launch a new window where you can download a free copy of the software.
| Disclaimer | Notice of Privacy Practices | Patient Bill of Rights | Contact Us |
| © 2010 CMC - NorthEast |
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© 2010 Carolinas HealthCare System | |