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 will allow you to provide the most accurate and thorough information about your child, and it will save you time at check-in when you arrive. 

We offer two really great options: (1) electronic webforms and (2) PDF paper forms. Electronic webforms can be submitted via your online patient portal account and are synced with your patient chart. Downloadable PDF paper forms, available in English and Spanish, can be printed out at home, completed by hand or electronically, and brought into the office at your appointment. 

If you are unable to complete new patient forms before your appointment, please arrive at least 15 minutes to complete the forms in their entirety. Thank you!

New Patient Webforms via Online Patient Portal 

Please go to the My Account tab at the top of our homepage, and click Create or Forgot Password button. Your username is the email address you provided when scheduling your appointment. From there, 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).

Should you have any issues, 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. 

New Patient Forms in English

English New Patient Intake Forms 2021
English New Patient Intake Forms for Medicaid-Eligible Patients 2021

 

Formularios en español para las pacientes nuevos

Spanish New Patient Intake Forms 2021
Spanish New Patient Intake Forms for Medicaid-Eligible Patients 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