New Patient Forms
Choosing a pediatrician is an important decision for your family. Is Pirate Pediatrics a good fit for you?
Current Patient Visit Forms
You will receive a notification via My Kid’s Chart to electronically complete visit forms prior to the appointment. If you need assistance, please call our administrative staff at 252-364-8790 or send a secure message via My Kid’s Chart. Failure to complete forms electronically prior to the appointment may result in the need to reschedule the appointment. Copies are available in the links below should you desire a paper copy for your records.
Asthma
Anxiety/Depression
M-CHAT (Modified Checklist for Autism in Toddlers)
Postpartum Questionnaire
School Forms
Prior to dropping off a form(s), please complete the parent portion. After five business days, your form(s) will be available for on my Kid’s Chart and/or in our office for pickup. Fees for form completion may apply. Please see form policy.
Pitt County School Forms
NC School Health Assessment Form (Kindergarten physical form)
NC High School Athletic Association Sport Pre-participation Examination Form
Allergy and Anaphylaxis Emergency Plan
Consent for Information Exchange
Medical Statement for Students with Unique Mealtime Needs for School Meals
Health Assessment Transmittal Form
Authorization for Medication
Concussion Return-To-Learn Recommendations
Licensed Health Care Provider Concussion Evaluation Recommendations
Put out into deep water, and let down the nets for a catch…Don’t be afraid; from now on you will fish for people…
Luke 5:1-11