940 SE Cary Parkway,Suite 200
Cary, North Carolina 27518
Phone: (919) 859-9991
Fax: -(919) 859-6595

Forms

New Patient Forms

New patients please complete these five forms and bring with you prior to your visit:

1. Patient Information Form

2. New Patient Questionnaire

3. Western Wake's Financial Policy

4. Notice of Privacy Practices

5. Disclosures & Consents

Other Forms

Records Release Form (Outgoing Patients)

Records Release Form (Incoming Patients)

Patient Complaint Form

Waiver of Advance Beneficiary Notice

Wake County Public School System Forms

Kindergarten Health Assessment Report

Parent Request and Physician's Order Form Wake County Public School System

High School Athletic Participation Form

Middle School Eligibility Requirements and Athletic Participation Form

Beginning May 1, 2007, Western Wake Pediatrics will implement the following policy as it relates to completing forms:

Patients requiring a form completed by our office for school, camp, sports, pre-school, medication administration forms, or any other form that requires a physician’s signature, if brought in conjunction with your child’s well/physical exam visit, the office will complete the form at no additional cost to the parent. Please ensure that you complete all components of that form prior to your child’s arrival at our office. Western Wake Pediatrics encourages parents to bring the form with them as we may not have the most up to date required form for your child at hand.

Should the necessary forms not be presented by the parent at the time of your child’s well/ physical exam visit and it is brought in or mailed to our office for completion after their well/physical exam visit, you will be subjected to a $5.00 administrative fee for each form/each child that will be due upon Western Wake Pediatrics’ completion of that form. If you are requesting that our office mail your child’s form back, you will need to send payment along with that form. Please be aware that this $5.00 fee is not covered by your medical insurance policy.