New Patient Forms

Please correct the errors described below.


Please list all children in the family even if the child is not being seen today.

Add another child


Mother/Legal Guardian

Father/Legal Guardian

  • If address is same as above, you can leave it blank

Please provide any applicable legal documents.

    Please upload a file

    EMERGENCY CONTACT (other than parents or legal guardians)

    Add another emergency contact

    To the best of my knowledge the above information is complete and accurate.

    Consent to call, text and email. Parent/Legal Guardian authorize the Starlight Pediatrics representative or the provider to mail, call o e-mail me with communications regarding the child(ren)’s healthcare, including but not limited to appointment reminders referral arrangements, laboratory results or financial information regarding my services, including insurance claims. I understand that I have the right to rescind this authorization at any time by notifying Starlight Pediatrics PLLC. to that effect in writing.

    Consent to retrieve prescription history. Parent/Legal Guardian consent to retrieval of the child(ren)’s prescription history from external sources such as SureScripts network. This information is used to ensure the safety and accuracy of your prescription service and to coordinate care with other providers.

    I have read and acknowledge the content of this Disclosures and Consents notice above.


    As a parent/legal guardian, I authorize that in my absence, the following person(s) to make decisions and/or obtain information regarding my child’s health care. Such duties may include but are not limited to:

    [1] The power to provide for such health care at any hospital or institution, or the employing of any physician, dentist, nurse, or other person whose services may be needed for such health care.

    [2] Consent to and authorize any health care, including administration of anesthesia, x-ray examination, performance or operations, and other procedures by physicians, dentists, and other medical personnel except the withholding or withdrawal of life sustaining procedures.

    Names of Authorized Persons who have the above listed permissions:

    Add additional authorized person

    This signed consent shall be effective from the date of my signature, if any changes are needed, then I will need to update this information with another signed consent.

    By signing below, I indicate that I have understanding and the capacity to communicate health care decisions and that I am fully informed as to the consents of this document and understand the full import of this grant of powers to the agent named herein. Furthermore, I may request to change or update this form at any time.

    In addition to the statement above, I am aware and fully understand that a responsible adult has to be with the patient at all times, from arrival to check out time. Also, no verbal consent is allowed via phone or email.

    I have read, and understood all of the terms and conditions contained herein.


    I hereby give my consent for STARLIGHT PEDIATRICS to use and disclose protected health information (PHI) about me to carry out treatment, payment and health care operations (TPO). (The Notice of Privacy Practices provided by STARLIGHT PEDIATRICS describes such uses and disclosures more completely.)

    I have the right to review the Notice of Privacy Practices prior to signing this consent. STARLIGHT PEDIATRICS reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to: OFFICE MANAGER 500 HOLLY SPRINGS RD STE 101 HOLLY SPRINGS NC, 27540.

    With this consent, STARLIGHT PEDIATRICS may call my home or other alternative location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any calls pertaining to my clinical care, including laboratory test results, among others. With this consent, STARLIGHT PEDIATRICS may mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked “Personal and Confidential.”

    With this consent, STARLIGHT PEDIATRICS may e-mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. I have the right to request that STARLIGHT PEDIATRICS restrict how it uses or discloses my PHI to carry out TPO. The practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement. By signing this form, I am consenting to allow STARLIGHT PEDIATRICS to use and disclose my PHI to carry out TPO. In order to comply with HIPPA requirements and to maintain confidentiality of protected health information (PHI), only emails and text messages requesting follow up or non-urgent appointments will be attended. However, parents/guardians should not send PHI or patients’ pictures via email or text message to the physician. Starlight Pediatrics will attend your requests via phone and it is no able to reply emails and text messages that bridge HIPPA laws.

    I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, STARLIGHT PEDIATRICS may decline to provide treatment to me.

    I have read, and understood all of the terms and conditions contained herein.


    Thank you for choosing Starlight Pediatrics PLLC. We are committed to providing you quality medical care and building a lasting relationship with you. As part of this relationship, we wish to establish our expectation of your financial responsibility.

    Guarantor: All patients 18 years and older carry financial responsibility, with the exception of disabled adults with a legal guardian. In such cases, financial responsibility rests with the legal guardian. The accompanying adult of a minor, 17 years and younger, is financially responsible for services rendered to the minor. We are not party to your child support order or divorce decree.

    Self-Pay: Patients without insurance coverage will be required to pay for all services at the time they are rendered. We do offer a discounted rate to self-pay patients. We also offer a payment plan to qualifying patients.

    Insurance Collection: Your medical insurance policy is a contract between you and your insurance carrier. As a courtesy, we will bill your medical insurance carrier for the services we provide. We will be diligent in making sure your insurance is filed accurately and promptly. We will always ask for updated insurance, demographics, and contact information at your appointment. Please be sure you provide us with the most up-to-date information and insurance card. Outdated information will cause delays in processing your claim and may lead to out of pocket expenses for you. If you are unable to provide current insurance information, or we are unable to verify coverage through your insurance carrier at the time of service, you will be responsible for payment prior to services being rendered. Should your insurance company pay for those services, we will gladly refund/reimburse you. We will make all the efforts to inform you in advance what potential charges you may have that may not be covered by your insurance, but these charges may change after your claim has been processed. You are responsible for knowing and understanding your insurance benefits and coverage.

    Co-pays, Outstanding Balances, and Fees: All co-payments, outstanding balances and fees for service not paid by your insurance policy are your responsibility and due at the time services are rendered. Payment of any fees not collected at the time of service, for any reason, is expected within 30 days. Any past due balance not paid will be turned over to a collection agency after 120 days. I understand that if I fail to make payment when due and my account becomes delinquent or is turned over to a collection agency or attorney for collections, that I, the undersigned, shall pay all collection agency fees, court costs and attorney fees, and risk being dismissed from the provider care of Starlight Pediatrics PLLC.

    Physical Examinations (Well Visits): Our providers will welcome discussing and/or providing any of the services that may not be covered by your medical health plan during your physical examination. However, please keep in mind that if your medical health care plan does not allow for or cover this additional service on the day of your physical, then you will be responsible for any charges related to that additional service.

    No Show / Cancellation Policy: Missed appointments represent a cost to us and other patients who could have been accommodated. Appointments missed / not cancelled at least 24 hours before the appointment time will result in $35 fee. No show / cancellation fees are not covered by insurance and are your responsibility. This fee will need to be paid in full before you will be permitted to schedule another appointment. Four (4) no shows / late cancellations within one (1) year time span are considered excessive and will result in being dismissed from the practice.

    Forms Charge: Our providers can help you to complete forms on the same day of the appointment. Requests to complete forms during any other time (school/day care forms, disability forms, medications needed for school among others) will incur a $10 fee. This fee is not covered by insurance. Payment is expected before forms will be released.

    Medical Records: Request of medical records will incur a $20 fee. This amount is to cover the costs incurred in searching, handling, copying, and mailing medical records to the patient or the patient's designated representative.

    Past Due Payments: If you are experiencing financial hardship or are unable to pay your bill in its entirety, please contact our Office Manager to discuss payment options. Patients with a past due balance or who have missed a payment, will not be permitted to schedule an appointment until payment arrangements have been made with our billing department. Balances that remain unaddressed after ninety (90) days will be sent to collections. The patient will be dismissed from the practice and we will no longer be able to provide services.

    Returned Checks: A $25 fee will be charged on all returned checks. Additionally, we will no longer be able to accept checks from you for yourself or any members of your family.

    High deductible plans: With High Deductible Insurance plans, patient/family is responsible to meet the yearly deductible before the insurance carrier cover any medical expenses. If you have a high deductible plan, you will be required to pay the cost of the appointment in advance. If you don’t want to make the payment in advance, we request that you provide us with a valid credit card, so we can charge the amount of the deductible after the claim is processed.

    Automobile Accidents: If the reason for your visit is an automobile accident, please know that we will be happy to provide treatment but only on a self-pay basis. Starlight Pediatrics, PLLC will provide you with a detailed receipt upon request in case you chose to file to your insurance carrier personally.

    Transfer of care: When transferring care to another provider, we will request and require you to close out any balances due.

    Starlight Pediatrics PLLC reserves the right to dismiss any patient from this practice who consistently fails to meet this policy or who refuses to sign this agreement. By signing below, I understand and agree to the terms of this office's financial policy.

    I have read, and understood all of the terms and conditions contained herein.


    Starlight Pediatrics has carefully reviewed our approach to vaccinations in our practice. There are several factors that we feel have a bearing on this vaccine policy. Our practice wants to ensure all of our patients, as well as the community at large, are as healthy as possible. One of the most important public health advancements has been the development of vaccinations, so we strongly believe that all children should be immunized. Because of vaccines, many diseases have been eliminated or have become uncommon. Scientific research has consistently and overwhelmingly shown that vaccines are not only effective but also safe. To not have a child vaccinated not only puts that child at risk, but everyone with whom he or she comes into contact. That includes family members, classmates, and other children in our waiting room.

    With these issues in mind, the following reflects our vaccine policy:

    Starlight Pediatrics follows the recommended schedule of the American Academy of Pediatrics (AAP) and the Centers for Disease Control (CDC). We look forward to providing the best care possible for our patients and their families. We respect the rights of all parents/guardians to make decisions and understand that you also want what is best for your children. We firmly believe in the effectiveness of vaccines to prevent illness and to save lives. Based on all available literature, evidence and current studies, we do not believe that vaccines cause autism or other developmental disabilities. Furthermore, the thimerosal preservative, which has been removed from almost all vaccines, has never been shown to cause autism or other developmental disabilities.

    We want to assure you that vaccines are safer today than they have ever been and that it is safe to give multiple or combination vaccines at the same office visit. This is because the reactivity of the individual vaccines is a tiny fraction of what a child’s immune system would be faced with if it were exposed to the actual diseases.

    We firmly believe that much of the protection of vaccines comes from mass immunity. Most vaccines produce immunity in 90-95% of children. The remaining 5-10% who do not produce immunity are protected from mass immunity, meaning that a highly vaccinated population limits the spread of most infections. As more people choose not to vaccinate, mass immunity will become absent. Now more than ever, it is important to protect those who choose to vaccinate their children from those who elect not to vaccinate.

    Our policy is written to emphasize the importance of vaccinating children. We recognize that the choice may be a very emotional one for some parents. We will do everything we can to provide education and information that vaccinating according to the schedule is the appropriate thing to do. Please be advised refusing vaccines can put your child at risk for serious illness or even death and goes against our medical advice as providers at Starlight Pediatrics. We follow the recommendations of the AAP and CDC.

    If despite our recommendations, you feel you cannot follow the AAP and CDC recommendations for these vaccines, we will ask you to find another health care provider who shares your views. We provide urgent care service to your child/ren for 30 days starting today. After this period is over, your child/ren will be deactivated and no further service will be provided. We do not keep a list of such providers, nor would we recommend any such providers. Please recognize that by not vaccinating, you are putting your child at unnecessary risk for life-threatening illness and disability, even death.

    I have read, and understood all of the terms and conditions contained herein.


    The current CDC (Centers for Disease Control and Prevention) vaccine schedule has been developed by top experts and is designed around the way your child’s immune system works. On occasion, due to a parent’s request, we may alter the schedule, however Starlight Pediatrics highly recommends that you do not alter it.

    At this time, insurance companies will not pay for the visit associated with an alternative vaccine schedule. Therefore, due to the additional cost of staffing and supplies, we have found it necessary to institute a $25.00 charge per visit. The charges must be paid at the time of the visit.

    By signing below, I indicate that I have read and understand this form. All of my questions and concerns were solved at the time of the visit.

    I have read, and understood all of the terms and conditions contained herein.

    DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

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