Patient Forms

Thank you for visiting Holly Springs Pediatrics. Below you will find our most up-to-date patient forms and policies. Please contact our office for any additional information or forms you may need.

Patient Forms

Appointment Scheduling
Divorce/Separation Custody Policy
Billing/No Show Policy
Over 18 Consent Form
Payment Policy
Parental Authorization to Treat Minor Child
Medical Release Form

HIPAA Forms

HIPAA Form
Patient Policy Acknowledgement Form

ADHD Forms

Vanderbilt Parent Informant
Vanderbilt Parent Informant Follow Up
Vanderbilt Teacher Informant
Vanderbilt Teacher Informant Follow Up

School Forms

**For school health assessment forms, please obtain these forms from your child’s school to ensure we have the most up to date forms**
Wake County Medication Form
Johnston County Medication Form
Daycare Form