7918 Download New Patient Forms, Financial Policy and Practice Policy Info

Streamline Your Visit

Prepare for your visit here with forms you can fill out online or download and print! In the near future we will have a fully-functioning electronic patient portal, so check back!

YOUR FIRST VISIT

If you are a new patient to Cape Fear Pediatrics, or if you have significant changes to make in your child's medical history, insurance, or demographic information, please print out and fill in the appropriate form below. Also, please ask any provider who has cared for your child in the past to forward records to our office, fax number (910) 392-5654.

Financial Policy

Patient Registration

Privacy Practices

6 MONTH WELL CHILD VISIT

We use the Ages & Stages questionnaire to evaluate your infant's development at this visit. You're welcome to fill it out in our office, but you may find it easier to do at home. Follow this link to begin an online account for your child. There you and your child's provider can track his or her development over time! Remember to tell our front desk staff if you've completed the form online.

12 MONTH WELL CHILD VISIT

This is another visit where we use the Ages & Stages questionnaire to evaluate your child's development. Just follow this link to get started!

18 MONTH WELL CHILD VISIT

This visit includes both an Ages & Stages evaluation and also a screening for early signs of autism spectrum disorders. For the online version of Ages & Stages, click here. For an easy-to-use online version of the M-CHAT autism screening tool, click here. Please do print out your child's M-CHAT results to share with the provider at your visit/!

24 MONTH WELL CHILD VISIT

This visit, just like the 18-month visit, includes both Ages & Stages and M-CHAT developmental screens. Click here for the Ages & Stages, and click here for the M-CHAT!

3 YEAR WELL CHILD VISIT

This visit includes an Ages & Stages developmental evaluation, which you can access here.

4 YEAR WELL CHILD VISIT

This visit includes an Ages & Stages developmental evaluation, which you can access here.

5 YEAR WELL CHILD VISIT

This visit includes an Ages & Stages developmental evaluation, which you can access here.

6 TO 10 YEAR WELL CHILD VISITS

The provider will assess development during the visit, but there are no special forms to fill out at these ages.

OLDER CHILD/TEEN WELLNESS EXAMS

Cape Fear Pediatrics complies with North Carolina law regarding confidentiality for teenaged patients. During adolescent wellness exams the provider will request a few minutes alone with the patient to review any concerns or behaviors the patient may want to discuss privately. We feel strongly that problems are best handled with family support, and we urge our patients to involve their parents in finding solutions. Law also mandates that we assist teens who are suicidal, homicidal, or victims of abuse, with or without their consent.

 

Starting at age 11 we ask our patients and their parents to fill out an age-appropriate Guidelines For Adolescent Preventive Services (GAPS) questionnaire, as recommended by the American Academy Of Pediatrics and the American Medical Association. These forms have proven very effective at helping identify patients who are at risk of suicide, poor school performance, substance abuse, and high-risk sexual activity. Encouraging your child/teen to fill out these forms honestly helps us intervene early to keep our patients as safe and healthy as possible!

 

Parents GAPS Form (All Ages)

 

Younger Adolescent GAPS Form (Ages 11-14)

 

Middle-Older Adolescent GAPS Form (Ages 15-21)

 

ADHD EVALUATIONS

 We will soon have documents for children visiting us for suspected or confirmed attention deficit/hyperactitity disorder (ADHD).

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Contact Information

Cape Fear Pediatrics

Wilmington Office
3505 Converse Drive
Suite 200
Wilmington, NC 28403

Phone:
910-392-5634

Fax:
910-392-5654
Hampstead Office
14057 Highway 17
Suite 200
Hampstead, NC 28443

Phone:
910-270-3673

Fax:
910-270-0529

 

 

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