Patient Forms

For your convenience, below is a list of the most commonly used forms in our offices. If you are a new patient, you can fill out the new patient forms and bring them with you to your appointment.

Forms can be downloaded using Adobe Acrobat and completed prior to your office visit.

CHKD Pediatric Practice Forms

Patient Registration

• New Patient Registration Form

Medical History Forms

• Medical Records Release Form (Authorization To Use Or Disclose Protected Health Information)
• Medical History Form

School Entrance Forms

• Virginia School Entrance Form (For high school and middle school students) 
  
• North Carolina School Entrance Form

Sports Physical Forms

• VHSL Sports Physical Form
• NCHSAA Sports Physical Form

Consent Forms

• Treatment and Payment Consent - Virginia
• Treatment and Payment Consent - North Carolina
• Treatment and Payment Consent - Virginia (Spanish)
• Authorization and Consent

ADHD/ADD

• ADHD cardiac screening questionnaire
• NICHQ - Assessment scale (for parents) 
  • NICHQ - Assessment follow-up (for parents)
• NICHQ - Assessment scale (for teachers) 
  • NICHQ - Assessment follow-up (for teachers)

Hospital Forms

Patient Privacy Forms

• English
• Spanish

Additional Hospital Information & Forms

• Your Rights and Responsibilities
• Financial Assistance Application Form
• Request to Release Hospital Medical Records
• Adult Patient's Authorization to Disclose PHI