381 Ruin Creek Road
Henderson, North Carolina 27536

Call- (252) 430-0666
Fax- (252) 430-7503

Portal/Bills Español



Please print and fill out these forms prior to your visit.

Click below to download the forms in Acrobat Reader:

Consent for Release of Protected Health Information Form (new patients or if you have been to any other providers)

Registration Information Form (new patients)

Medicare Secondary Payer (MSP) Form (medicare patients)

Health History Forms (2 Pages) (new patients, physicals, yearly)

M-CHAT Form – Ages 18 and 24 Months

Pediatric Symptom Checklist (PSC) Form, Ages 6-10 years

Pediatric Symptom Checklist – Youth Report (Y-PSC) Form, Ages 11-17 years





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