New Patient Forms and Questionnaires

 New patients/families, please complete these ten forms and email them with a copy of the front and back of your health insurance card, prior to your first visit appointment being scheduled to Angie Deharo, New Patient Registrar at  Please note:  Medical records must be received prior to your new patient appointment being scheduled.  Please complete the New Patient Release of Records Incoming Patients form and send that to your previous Pediatric provider.  If you have any questions concerning these forms please call us at (919) 859-9991 option 8.

  1. Message for Patients
  2. New Patient Release of Records Incoming Patients
  3. Patient Information Form
    Informacion del Paciente
  4. New Patient Questionnaire
    Cuestoionario para Pacientes Nuevos
  5. Western Wake's Financial Policy
    Politica Financiera del Paciente
  6. Notice of Privacy Practices
    Advertencia de la Privacidad de la Practica
  7. Disclosures & Consents
    Forma de registro de pacientes - Clausulas y Consentimientos
  8. Patient Portal Consent Form
  9. Medical Authorization Form
  10. Kindness Policy

Other Forms

Wake County Public School System Forms

Western Wake Pediatrics has implemented the following policy as it relates to completing forms:

Patients requiring a form completed by our office for school, camp, sports, pre-school, medication administration forms, or any other form that requires a physician’s signature, if brought in conjunction with your child’s well/physical exam visit, the office will complete the form at no additional cost to the parent. Please ensure that you complete all components of that form prior to your child’s arrival at our office. Western Wake Pediatrics encourages parents to bring the form with them as we may not have the most up to date required form for your child at hand.

Should the necessary forms not be presented by the parent at the time of your child’s well/ physical exam visit and it is brought in or mailed to our office for completion after their well/physical exam visit, you will be subjected to a $5.00 administrative fee for each form/each child that will be due upon Western Wake Pediatrics’ completion of that form. If you are requesting that our office mail your child’s form back, you will need to send payment along with that form. Please be aware that this $5.00 fee is not covered by your medical insurance policy.

Vanderbilt Forms

Ages & Stages

Please note:  please complete both the ASQ and MCHAT forms prior to your child’s 18 month / 24 month physical.

Developmental Screening Tools

Care Management

Appointments Pediatric Services Meet Our Pediatricians in Cary, NC and Raleigh areas Patient Center for Western Wake Pediatrics office in Raleigh NC area Satisfaction Survey for Western Wake Pediatrics
Office Hours
Monday - Thursday
Regular Hours
Extended Hours
7:45 am - 12:30 pm
1:30 pm - 5:00 pm
5:15 pm - 6:45 pm
Regular Hours
8:00 am - 12:30 pm
1:30 pm - 5:00 pm
Regular Hours
8:30 am - 12:00 pm
Sunday closed
Read About Walk-ins >>