New Bern, Havelock, and Maysville Locations-
Serving the communities of Vanceboro, Pamlico County,
Newport, Morehead City, Pollocksville, Trenton,
Jacksonville, Swansboro and Richlands.
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Patient Forms

In order to save time when you get to our office, we have provided the following forms for you to download, complete and bring to your visit.

General Forms:

  • Family Information
  • Medical Release Form- (Transfer TO us) español
  • Medical Release Form (Transfer AWAY from Us)
  • Personal Use Medical Release Form
  • Notice of Privacy Form/ HIPAA
  • Financial Policy
  • Patient Feedback Form
  • Topic Info Handouts (Children's Health Network)
  • Patient Satisfaction Survey

Well Visit Forms:

  • Well Child Visit Schedule
  • 1 Month Well Pre-Visit  Form (español)
  • 2 Month Well Visit (No Forms Needed)
  • 4 Month Well Visit (No Forms Needed)
  • 6 Month Well Pre-Visit Forms (español)
  • 9 Month Well Visit (No Forms Needed)
  • 12 Month/  Well Visit Packet (español)
  • 15 Month Well Visit (No Forms Needed)
  • 18 Month Well Pre Visit Form (español)
  • 24 Month Well Pre Visit Form (español)
  • 3 Year Well Pre-Visit Forms (español)
  • 4 Year Well Pre-Visit  Forms (español)
  • 5 Year Well Visit Packet (español)
  • 6- 12 Year Well Pre-Visit Form
  • 12 Year and Older Well Pre-Visit Forms

Physicals:

  • High School Sports Participation
  • General Sports Participation History Form
  • General Physical Form 

Asthma Forms:

  • Asthma Self Assessment Test- (English, Español) 
  • Peak Flow Diary

ADHD:

  • Vanderbilt Teacher ADHD
  • Vanderbilt Parent ADHD

School Forms: 

  • Craven County School Forms
  • Carteret County Forms
  • Onslow County Forms

Vaccine Forms and Information:

  • Immunizations

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Find Us

New Bern - (252) 633-2900

fax: 252-633-9609

Havelock - (252) 447-8100

fax: 252-447-1900

Maysville - (910) 743-2022

fax: 910-743-1283

Urgent Calls After Hours:
(252) 633-2269

Map & directions

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Pediatrician - New Bern, Havelock, Maysville, including the
communities of Bayboro, Newport, Morehead City, Jacksonville, Swansboro and Richlands

703 Newman Road New Bern, NC 28562  Fax:252-633-9609 | Phone: (252) 633-2900
218 Stonebridge Sq. Havelock, NC 28532  Fax: 252-447-1900 | Phone:  (252) 447-8100
1004 Jenkins Ave Maysville, NC 28555  Fax: 910-743-1283 | Phone:  (910) 743-2022

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