Carolinas HealthCare System
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Patient Forms

Wesley Chapel Family Medicine provides new and existing patients the following forms for download to fill out and bring to your appointment as requested.

Patient Forms and Release of Medical Records

New Patient Packet (Adults) (PDF)

Included in this packet:

  • Patient Registration-Adult
  • Adult Patient History
  • Authorization for Release of Health Information
  • Acknowledgement Form (HIPAA)
  • Payment Policy and Patient Statement of Responsibility
  • How Did You Hear About WCFM?

New Patient Packet (Children) (PDF)

Included in this packet:

  • Patient Registration-Child
  • Minor Child History Form
  • Authorization for Release of Health Information
  • Acknowledgement Form (HIPAA)
  • Payment Policy and Patient Statement of Responsibility
  • How Did You Hear About WCFM?
  • Children's Medical Report
  • Sport Pre-participation History Form

Notice of Privacy Practices - English (PDF)

Notice of Privacy Practices - en Español (PDF)

Assessment Forms

NICHQ Vanderbilt Assessment Scale (PDF)

Autism Screening (modified checklist for Autism in Toddlers) (PDF)

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