Carolinas HealthCare System
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Patient Information

Providence Pediatrics provides new and existing patients the following forms for download to fill out and bring to your child's appointment as requested. Also find Online Resources below for vaccination information.

New Patient Forms

Please print and complete the New Patient Packet (PDF) and bring to your next appointment.

Request for Medical Records
Authorization for Release of Health Information (PDF)

Eye Chart
Click here to view the Eye Chart (PDF) for younger children

Assessment Forms
NICHQ Vanderbilt Assessment Scale

Parent Informant (PDF)
Parent Informant (PDF) - Follow up
Teacher Informant (PDF)
Teacher Informant (PDF) - Follow up

Other Forms
MCHAT Autism Screening Form (PDF) (Modified Checklist for Autism in Toddlers)

Online Resources

Please refer to any of the four online sources below for more information on vaccination:

Centers for Disease Control and Prevention:

  • Created and operated by the Centers for Disease Control and Prevention, this site provides thorough, timely information on a wide variety of vaccine-related topics.
  • On this site, you'll find updated immunization schedules, information specially designed for parents, and more.

National Network for Immunization Information:

  • This-up-to-date, science-based Web site is designed to provide information for a variety of audiences-health care professionals, the media, and the public.
  • Visit and you'll find updates on vaccines, a quick reference section on vaccine-preventable diseases, and more.

American Academy of Pediatrics:

  • A division of the American Academy of Pediatrics, the Childhood Immunization Support Program (CISP) provides a wealth of content about childhood vaccines.
  • While browsing the site, be sure to click on the "Families" section. There, you'll find a helpful Frequently Asked Questions (FAQ) section, information about school vaccine requirements, and more.

American Academy of Family Physicians:

  • In addition to providing information for physicians, the American Academy of Family Physicians site is a useful source of information for parents.
  • On the home page, be sure to click on the "Patients" section. From there, you'll find a wealth of information about vaccines, children's health, and more.
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