Patient Forms

We look forward to meeting you and your child at the first appointment! We encourage you to complete all forms at your convenience prior to your appointment. This way you can provide the most accurate and thorough information about your child, and you can enjoy a simple check-in with your child!

In order to do so, please email us at info@CarolinaPedo.com or call (919) 570-0180 to reach a front representative who may assist you in scheduling and setting up your webportal account. You will then be able to complete the majority of the forms electronically on a PC or Mac computer, tablet, or mobile device (Safari browser on iPhones, and any browser on Android phones).

If it is most convenient for you to print out the forms and complete them at home, you may find a downloadable PDF of our New Patient forms below:

New Patient Forms in English

English New Patient Intake Forms 2021

English New Patient Intake Forms Medicaid-Eligible 2021

 

Formularios en español para las pacientes nuevos 

 

Spanish New Patient Intake Forms 2021

Spanish New Patient Intake Forms Medicaid-Eligible 2021

Notice of Privacy Practices 

Notice of Privacy Practices (English) - PDF
Notice of Privacy Practices (Spanish) - PDF

 

ready to get
started?

(919) 570-0180
Monday - Friday 6:45AM - 5PM