Living Water Pediatrics

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Medical Forms

We are excited that you have chosen to become a part of our pediatric practice family! We require the New Patient Forms to be filled out prior to your first visit to ensure that your membership and your child’s health records are up-to-date prior to receiving care.

New Patient Forms

New Patient History form
Parental Consent to treat minor
HIPAA release
Authorization to release information
Permission to discuss Protected Health Information
Office Policies
Pharmacy Form

Physical Forms

Child physical form
NC Kindergarten form
CMS Middle School Sports Physical form
CMS High School Sports Physical form

Medication Forms

CMS Medication Authorization form
CMS Asthma Action Plan 

ADHD Forms

Initial Parent Vanderbilt form
Initial Teacher Vanderbilt form
Follow up Teacher Vanderbilt form
Follow up Parent Vanderbilt form

Developmental Screenings

MCHAT revised form

 

 

330 Billingsley Road, Suite 101
Charlotte, NC 28211
Phone: (980) 260-0900
Fax: (980) 260-0901
Monday: 8:00 am to 5:00 pm
Tuesday: 8:00 am to 5:00 pm
Wednesday: 8:00 am to 5:00 pm
Thursday: 8:00 am to 5:00 pm
Friday: 8:00 am to 5:00 pm
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