Medical Forms

At Chapel Hill Pediatrics and Adolescents, we strive to make the paperwork as painless as possible. Patients can find forms below to request their medical records, as well as outside lab testing. We do not accept unsolicited photos or documents.

Requesting Medical Records from Chapel Hill Pediatrics

To request records from Chapel Hill Pediatrics and Adolescents, please log in using the fields below. Once you are logged in, choose the “Request Medical Records” option. If you do not have an account on our website, please call our office so we can send you an account activation email. The fee for medical records requests shall follow the N.C. General Statues 90-411 Record copy fee. Return all completed forms to forms@chapelhillpeds.com.

There will be a charge for all records leaving Chapel Hill Pediatrics. The maximum fee for each request shall be seventy- five cents (75¢) per page for the first 25 pages, fifty cents (50¢) per page for pages 26 through 100, and twenty-five cents (25¢) for each page in excess of 100 pages, provided that the health care provider may impose a minimum fee of up to ten dollars ($10.00), inclusive of copying costs. You may also bring your own flash drive, unopened in the original packaging. Please allow up to 30 business days for our office to process your request and provide you with your records.

Medical Record Release (Leaving Chapel Hill Pediatrics)

Medical Record Request (Coming to Chapel Hill Pediatrics)

Minor Consent to Release Information to Parent/Guardian

Patient Forms for Outside Lab Tests

Ordering outside labs and medical testing? You must have your ordering physician complete and sign the “Authorization for Outside Labs” before Chapel Hill Pediatrics can schedule your lab appointment.

Authorization for Outside Labs Form

Patient Forms for Behavioral Appointments

Vanderbilt Parent Form

Vanderbilt Teacher Form

Vanderbilt Parent Follow-up Form

Vanderbilt Teacher Follow-up Form

ADHD Daily Log

Patient Forms for Head Injury/Concussion Appointments

Please download and print the following form for your child’s head injury/concussion appointment.

Concussion Symptom Log

Patient Forms for Asthma/ Asthma Follow Up Appointments

Please download and print the following for your child’s upcoming asthma/asthma follow up appointment.

Asthma Control Test 4-11yrs

Asthma Control Test

Consent for Treatment Form

Consent for Treatment of a Minor
If you have any questions, we’d be happy to answer them! Feel free to contact our office for information about our practice, policies or patient forms.

Sports Form

NCHSAA Sports Form