FORMS & POLICIES

New Patient Paperwork/ Update Form (English) 

New Patient Paperwork / Update Form (Spanish)

Records Release Form

***These forms must be turned in directly to our office. We do not accept new patient forms submitted via fax.***

Currently accepting siblings of established patients and children of prior patients only

Wilkes County Schools Medication Form 

Sports Physical Form 

NC Health Assessment Form (Preschool)  

Children's Medical Report (Daycare)  

Teacher Vanderbilt (ADHD) Form

Parent Vanderbilt (ADHD) Form

• ADHD Consult Policy : Vanderbilt forms are required for ADHD consults and must be completed by the parent/guardian and each teacher and returned to the clinic before we can schedule an appointment.  

• Billing Policy:

1. Co-pays and deductibles are due at the time of your visit. We accept cash, checks, and credit cards. Please remember that copays and deductibles are set by your insurance company, not by our clinic.

2. If you are experiencing financial hardship or need help with your bill, please contact our billing manager at 336-903-0147 (option 2). We are happy to discuss options, and a payment plan may be available.

3. Please make sure we have a current copy of your insurance card(s) on file so we can process your visits accurately and without delays. If your insurance changes at any time, just let our front office staff know.

4. If your insurance plan lists us as out of network or does not participate with us, payment in full will be due at the time of service.

5. If you do not have insurance, you will be considered a self-pay patient. We will provide an estimate of the cost for services before your visit, and payment will be due at check-in.

• Medication Refill Policy:  Please allow 48 hours for refills

• HIPPA: Wilkes Pediatrics follows all the HIPAA regulations. Medical information will not be released unless we have written authorization from you in the office. 

• After Hour Phone Service: 

~ Our after-hours phone service is available to help with urgent medical questions when the clinic is closed. When you call our main number after business hours, your call will be directed to our nurse triage service. A trained nurse will return your call and provide guidance based on your child’s symptoms.

Please note:

~This service is for urgent medical concerns only.
~ Non-urgent questions, medication refills, appointment requests, and paperwork needs will be handled on the next business day.
~ If your child is experiencing a medical emergency, please call 911 immediately or go to the nearest emergency department.