carolina
developmental
pediatrics
    
APPOINTMENT and FORMS
NEW PATIENTS
Our office sees new patients by referral only. We request you get a referral from your primary care physician.   Your pediatrician or primary care physician will need to complete the Referral Form and parents should fill out the Initial History Form . Both should be faxed or sent to our office. Please allow us a 2 weeks to process your paperwork. After processing we will send you a link to a rating scale via e-mail.  Please complete the on-line rating scale, which should take 20-30 minutes to complete.  When you finish the scale it will come back to us to be scored.  Your child's name will then go on our wait list for an appointment.  Please be advised that at the present time, we have approximately a 2 month wait for new appointments. Your patience is greatly appreciated.

Physicians within the UNC physicians network, please use the forms on the UNC-PN tab. 



 

Forms for NEW patients


Initial History Form (completed by parents)

Referral Form (completed by referring provider)

Consent & Financial Policy  (for review - you will sign in the office)

UNC Physicians Network (completed by UNC provider ONLY)


Current Patients

Rx Policy

Requests for medication refills should be sent to your pharmacy. This applies to both stimulant and non-stimulant medications.  This will expedite the process and an authorization will be sent directly to your pharmacy. 
If your pharmacy does not yet e-file stimulant (controlled substance) medication refills, please call the office at 919-362-5406 x 2 and leave a message with your name, the name and date of birth of the patient, the name and dose of the medication and how it is taken as well as the name and phone number of your pharmacy.  A refill will be transmitted to your pharmacy within 2 business days.  
Note the office is closed on Wednesday mornings and Fridays and these days do not constitute a business day.
We strongly recommend that you call for a refill when your child has 7 days of medication left.  This will insure that you do not run out of medication and allows time for prior approvals or other questions regarding medications.


Forms for CURRENT patients 

Medication Symptom Form

Clinical Attention Problems Scale (CAP Form)

Release of Healthcare Information (to CDPeds)

Release of Healthcare Information (from CDPeds)


We will be happy to fill out school, work or other forms.  Please allow 1 week for these forms to be completed.  Note that charges may apply.  Please see the financial policy for details.
 
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