Forms and Policies

Download new patient materials and other commonly used forms. Learn about the policies that help us provide you with the very best of care.

Office Visit Forms

Please print and complete applicable forms prior to your child’s visit. When you check-in, please let front staff know you have already completed the forms and brought them with you to the visit.

We may ask for some of these forms to be completed annually to ensure we have your most current and correct information.

All forms are in PDF format, viewable with Adobe Reader or any other PDF reader app.

Well visit forms

  • Periodic screenings are recommended by the American Academy of Pediatrics based on needs and age of the child. Below are some of the screening tools we use at Sanford Pediatrics. Please feel free to complete prior to the visit and bring the applicable forms with you to your appointment. If you are unable to do so they are available for you to complete at our office at the time of the visits.
  • Edinburgh Postnatal Depression Scale (EPDS)To be completed by birth mom at newborn visit, 1-2 week check, 2 month well check.English »Español »
  • Parents’ Evaluation of Developmental Status (PEDS)Due to copyright laws, our pediatric developmental screenings for younger children are not available online but are provided at each well child visit beginning at 6 months of age as recommended by the American Academy of Pediatrics.
  • Modified Checklist for Autism in Toddlers (MCHAT)To be completed at 18 month well check and 24 month well check.English »Español »
  • Pediatric Symptoms Checklist (PSC)To be completed by parents for well check visits for patients age 6-11 years.English »Español »
  • Youth Pediatric System Checklist (YPSC)To be completed by adolescent for well check visits ages 11-18 years.English »Español »
  • Patient Health Questionnaire (PHQ9)To be completed as desired or requested by physician.English »Español »
  • Screen for Child Anxiety Related Disorders (Child)To be completed by child.English »Español »
  • Screen for Child Anxiety Related Disorders (Parent)To be completed by parents.English »Español »

New patient forms

  • For your convenience you may print and complete the Patient Registration, Medical History, and Acknowledgement Forms, prior to coming for your First Visit at our office to bring with you. If you are unable to do so, you may complete them on arrival. Copies of our Patient Care and Privacy Policies are posted for your information and do not need to be printed unless you desire a printed copy for your records.
  • Patient Registration FormTo be completed before your first visit.English »Español »
  • Medical History FormTo be completed before your first visit.English »
  • Acknowledgement Form for Parent Care and Privacy PoliciesTo be completed before your first visit.English »Español »
  • Patient Care PolicyEnglish »Español »
  • Privacy PolicyEnglish »Español »

ADHD Forms

  • To be completed prior to visit to discuss possible ADD or ADHD or with medication changes or follow up appointments as directed by your pediatrician.
  • Vanderbilt Parent Assessment ScaleTo be completed by parents.English »Español »
  • Vanderbilt ADHD Diagnostic Teacher Rating ScaleTo be completed by academic teacher.English »

Asthma forms

  • Asthma Control Test (ACT)To be completed at each asthma follow-up appointment and well check in patients with asthma.English »Español »

Sanford Pediatrics Non-Discrimination Policy

Sanford Pediatrics, P.A. complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

Sanford Pediatrics, P.A, does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Sanford Pediatrics, P.A. provides with reasonable expectations and advanced informed notice language assistance services for individuals with limited English proficiency (LEP).

Appointments

Please call ahead for all preventative and sick care appointments.

Routine and same-day appointments are typically scheduled:

Monday – Thursday 8:00 am – 4:00 pm

Friday 8:30 am – 3:00 pm

After-hours scheduling is available for urgent care and limited routine visits:

Monday – Thursday 5:00 – 6:00 pm

Saturdays 9:00 am – 11:00 am

Walk-Ins

Walk-in sick patients may be given the next open appointment slot if available, but this is not guaranteed. Preventative visits will not be granted on a walk-in basis.

After-Hours Care

Our triage nurse and answering service are available when you have urgent questions and concerns that cannot wait until the next business day.

Accepted Insurance

We are in contract with the insurances listed below. If you are covered by another insurance plan please feel free to contact our office to inquire the status of our participation. For billing questions, please contact our office during normal business hours.

  • Blue Cross Blue Shield of NC (including out of state BCBS if they participate in the “BCBS Blue Card”)
  • Cigna Healthcare
  • First Carolina Healthcare
  • Great West (owned by Cigna)
  • MedCost
  • NC Medicaid (Lee County Carolina Access only)
  • NC State Employees Health Plan
  • NC HealthChoice
  • Tricare-Standard
  • United HealthCare

Immunization Policy & Schedule

At Sanford Pediatrics, we believe in the effectiveness of vaccines to prevent illnesses and save lives. We also believe in the safety of all of the vaccines that we provide in our office. We follow the CDC and American Academy of Pediatrics vaccine schedule. Please see our Patient Care Policy for a complete explanation of our Immunization Policy.

Two months

  • DTap (diphtheria, tetanus, and pertussis)
  • IPV (inactivated polio vaccine)
  • Hib (haemophilus influenzae type b)
  • Prevnar (pneumococcal conjugated vaccine 13)
  • Hepatitis B
  • Rotavirus

Four months

  • DTap (diphtheria, tetanus, and pertussis)
  • IPV (inactivated polio vaccine)
  • Hib (haemophilus influenzae type b)
  • Prevnar (pneumococcal conjugated vaccine 13)
  • Rotavirus

Six months

  • DTap (diphtheria, tetanus, and pertussis)
  • IPV (inactivated polio vaccine)
  • Hib (haemophilus influenzae type b)
  • Prevnar (pneumococcal conjugated vaccine 13)
  • Hepatitis B
  • Rotavirus

Twelve months

  • MMR (measles, mumps and rubella)
  • Varicella (chicken pox)
  • Prevnar
  • Hepatitis A

Eighteen months

  • DTap (diphtheria, tetanus, and pertussis)
  • Hib (haemophilus influenzae type b)
  • Hepatitis A

Four to five years

  • DTap (diphtheria, tetanus, and pertussis)
  • IPV (inactivated polio vaccine)
  • MMR (measles, mumps and rubella)
  • Varicella (chicken pox)

Ten years and older

  • Tdap (tetanus diphtheria and pertussis)
  • Menactra (meningococcal conjugate vaccine) – booster required at age 16
  • HPV (human papillomavirus virus) – boosters required two and six months after the first