Medical Forms

At Chapel Hill Pediatrics and Adolescents, we strive to make paper work as painless as possible. Patients can find forms below to request their medical records, as well as outside lab testing.

Requesting Medical Records from Chapel Hill Pediatrics

Medical RecordsTo request records from Chapel Hill Pediatrics and Adolescents, please log in using the fields below. Once you are logged in, choose the “Request Medical Records” option. If you do not have an account on our website, please call our office so we can send you an account activation email.

There will be a charge for all records leaving Chapel Hill Pediatrics. The entire chart is $8, and a digital PDF copy is available as well. You may bring your own flash drive, or a 1GB drive is also available for purchase in the office for $12. Please allow ten to fifteen business days for our office to process your request and provide you with your records.

Medical Record Release (Leaving Chapel Hill Pediatrics)

Medical Record Request (Coming to Chapel Hill Pediatrics)

 

Patient Forms for Outside Lab Tests

Ordering outside labs and medical testing? You must have your ordering physician complete and sign the “Authorization for Outside Labs” before Chapel Hill Pediatrics can schedule your lab appointment.

Please review our policy for outside labs and follow the steps listed to help make the process as smooth as possible! You may view and print a copy of our Authorization for Outside Labs Form below (please click to download):

Authorization for Outside Labs Form

 

Patient Forms for Behavioral Appointments

Please download and print the following forms for your child’s behavioral appointment. We request that completed forms be turned into our office 3-5days prior to your child’s appointment. Teacher forms should be given to all of your child’s teachers, tutors, coaches, etc. Any other information including but not limited to previous evaluations or testing would be helpful to have prior to your child’s appointment as well.

Vanderbilt  Parent Form

Vanderbilt Teacher Form

Vanderbilt Parent Follow-up Form

Vanderbilt Teacher Follow-up Form

ADHD Daily Log

Patient Forms for Head Injury/Concussion Appointments

Please download and print the following form for you child’s head injury/concussion appointment.

Concussion Symptom Log

Patient Forms for Asthma/ Asthma Follow Up Appointments

Please download and print the following for your child’s upcoming asthma/asthma follow up appointment.

Asthma Control Test 4-11yrs

Asthma Control Test

Consent for Treatment Form

Our consent for treatment of a minor child authorizes other family members/friends to bring your children in for appointments. We recommend having this form on file with our office in case of emergencies or situations (such as travel) where you may not be able to bring your children to an appointment.

Consent for Treatment of a Minor Child
If you have questions, we’d be happy to answer them! Feel free to contact our office for information about our practice, policies or patient forms.