Pediatrics

Patient Forms

All forms to be completed need to be dropped off at a Wilmington Health Pediatrics office.

There will be a charge for the following forms:

  • FMLA, Disability and/or Military forms will incur a $15.00 charge.
  • Sports physical and other forms not completed during a visit will also incur a $15.00 charge.
  • Forms related to medical therapies such as asthma action plans and/or meds at school forms will not incur a form charge.

Forms that are dropped off will be completed within 3 business days.

First Visit & Annual Updates

Kindergarten FORMS

Please carefully read the instructions below before downloading and completing the Kindergarten Form.

PRE-K FORMS

  • Your form CAN be completed if your child is 4 years old and has had a "4-year well-child check" within the past 12 months.
  • If your child is 4 years old but has not had a "4-year well-child check," you may schedule an appointment with the receptionist.
  • Your form CANNOT be completed at this time if your child is 3 years old.
  • If your child is not yet 4 years old, please hold on to your form.
  • Please call us and schedule a "4-year well-child check" for any available date after the child's 4th birthday. Forms can be dropped off at that time.

KINDERGARTEN FORMS

  • Your form CAN be completed if your child is 5 years old and has had a "5-year well-child check" within the past 12 months.
  • If your child is 5 years old but has not had a "5-year well-child check," you may schedule an appointment with the receptionist.
  • Your form CANNOT be completed at this time if your child is 4 years old.
  • If your child is not yet 5 years old, please hold on to your form.
  • Please call us and schedule a "5-year well-child check" for any available date after the child's 5th birthday. Forms can be dropped off at that time.

NORTH CAROLINA LAW:
IN COMPLIANCE WITH NORTH CAROLINA LAW, ALL STUDENTS ENTERING KINDERGARTEN MUST PRESENT A HEALTH ASSESSMENT (PHYSICAL EXAM REPORT) BY THE FIRST DAY OF SCHOOL ENTRY. THE ASSESSMENT MUST HAVE BEEN COMPLETED WITHIN 12 MONTHS OF SCHOOL ENTRY. IN ADDITION, NORTH CAROLINA LAW REQUIRES PARENTS/GUARDIANS TO PRESENT CERTIFICATION OF HEALTH ASSESSMENT ON THE FIRST DAY OF SCHOOL ENTRY. IF DOCUMENTATION IS NOT PRESENTED, PARENTS/GUARDIANS HAVE 30 CALENDAR DAYS TO PROVIDE DOCUMENTATION OR THE STUDENT SHALL BE EXCLUDED FROM SCHOOL UNTIL PROOF IS PROVIDED.

Medication at School

If your child needs medication at school, please download the proper form below. Please complete the appropriate items, and your provider will complete the rest of the form.

NCHSAA Return to Play Form

Pre-Participation Sports Screening

In accordance with North Carolina High School Athletic Association Guidelines, please download the form below and complete the information to the best of your ability. Your provider will complete the rest of the form during your visit.

RECORD TRANSFER

If you are new to Wilmington Health, please download and complete this form. This will allow us to have access to your records!

Asthma Forms