New Patient Forms (English)

Please correct the errors described below.


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

Add additional patient


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


    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.


    In my absence, the following person(s) have permission 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 and [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 whom 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/s at all times, from arrival to check out time. Also, no verbal consent is allowed via phone or email.

    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.


    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.

    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.



    Appointment Cancellation and No-Show Policy

    • For the health and convenience of others, it is important to keep your scheduled appointments. If you are unable to keep your appt, please contact our office as soon as possible so that we may offer it to another patient in need. Our office mandates a $25 No-Show fee which must be paid before scheduling your child’s next appointment.

    Financial/Insurance Policy

    • Prompt payment allows us to keep costs down. All copays, deductible amounts, and/or coinsurance payments must be collected at the time of service. Any balance on the account is due before the next appointment or within 30 of the date of the statement.
    • Patient balances more than 90 days overdue are subject to collection. Please contact our office to discuss options and avoid any overdue accounts. Our staff wants to help your family in any way possible.
    • As a courtesy, our office will bill your insurance for your visit. Please be aware that your insurance policy is an agreement between you and your insurance company. It is the guarantor’s responsibility to remit payment for the charges that are not covered by your insurance policy. It is important that you have a good understanding of your policy and what your responsibilities are for visits with your doctor.
    • Also please understand that our office estimates the expected payment by your insurance company. All claims are subject to medical necessity and any exclusion of your contract.
    • Please be sure to notify Starlight Pediatrics staff of any changes in your insurance. Failure to do so may result in increased patient responsibility amounts.
    • Starlight Pediatrics accepts cash, credit, or debit cards at the time of service. Starlight does not accept personal checks due to the occurrence of returned checks and unpaid fees.

    Prescription and Forms policy

    • Starlight Pediatrics is delighted to treat your child. If your child requires on-going medication(s) to treat ADHD/ADD or any behavioral/mental health concerns, an appointment is required by the American Academy of Pediatrics (AAP) and insurance providers. Our office does not fill controlled substances without a documented visit with the provider.
    • For all other refills, please call the office or use the convenience of the patient portal to request the refill. Our office requires 48 hours (excluding holidays and weekends) to complete refill requests. Please keep this policy in mind and be sure to request refills for your child’s medication in plenty of time to prevent them from running out.

    Preventative Visits (Physicals/ Wellness Checks)

    • Our office takes preventative health quite seriously. We encourage all patients to schedule regular physicals. Due to the contracts with insurance carriers, some patients whom have specific concerns at the time of the physical require out of pocket expenses to the parents. Our providers do all that they can to keep these costs to a minimum, but preventative and sick visits at the same time is subject to copays and deductible amounts according to your insurance carrier. Please direct any questions or concerns to our staff. It is a good idea to contact your insurance company to clarify such costs during preventative visits.

    All Policies are subject to updates, changes, and amendments. Please speak with our staff with any questions or concerns.


    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 and 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.


    The current CDC 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 altered 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.

    Please see the enclosed Frequently Asked Questions and Answers About the Vaccine Schedule from the American Academy of Pediatrics. If you still have questions or concerns, the doctors will be happy to discuss them with you.

    With my signature below, I

    legal guardian of

    understand the alternative vaccine policy presented. All of my questions and concerns were solved at the time of the visit.

    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.

    I have read and understood the following documents. I have had the opportunity to ask questions, which have been answered properly, as well as any further comment in this regards.

    My signature confirms, the statement above. I indicate that I have understood and I am fully informed of the forms given.

    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.

    Your information will be encrypted.