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

Divorce/Separation Custody Policy
Billing Policy
Over 18 Consent Form
Payment Policy
Parental Authorization to Treat Minor Child
Medical Release Form

HIPAA Forms

HIPAA Form
HIPAA Acknowledgement Form

ADHD Forms

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

School Forms

Kindergarten Assessment Form
Wake County Sports Physical Form
Wake County Medication Form
Johnston County Sports Physical Form
Johnston County Medication Form
Daycare Form