Under Federal Law, you have rights when it comes to your health information. Please review detailed information in our Notice of Privacy Practices. For more information, see the U.S. Department of Health and Human Services website.

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Notice of Privacy Practices

Aviso de Prácticas de Privacidad (en Español)

We ask that all patients and families abide by our practice's policies to ensure a positive experience through mutual understanding and aligned expectations. Please review our Policy Information Sheet for further details. 

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Policy Information Sheet

Code of Kindness

Divorce, Separation, Foster Care, & Custody Agreements Policy

Important Billing Information for Well Visits

We believe in vaccines! Vaccines are safe. Vaccines do not cause autism. One of the most important ways we can protect your child’s health and the health of our community is to vaccinate against deadly, preventable diseases. If you would like to discuss vaccines, our physicians welcome any questions or concerns. We follow the standard immunization schedule as recommended by the American Academy of Pediatrics and the Centers for Disease Control. We do not advocate alternative vaccine schedules, since there is no proven benefit. Any delays will only place your child at unnecessary risk. If you choose not to vaccinate, we ask that you find another healthcare provider whose medical philosophy is compatible with your views. Please view our Vaccine Policy for more information.

If you are joining our practice, please complete the Medical Information Release Form. We require that we receive your child's medical records before scheduling your first appointment.

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We request that you regularly update your information with our practice.

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Patient Demographic Form

Formulario Demográfico del Paciente (en Español)

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Your child’s medical records at Burlington Pediatrics are confidential under HIPAA law and will not be released to anyone without written consent. We charge a fee to copy records for attorneys, insurance companies and personal use as permitted by NC law. Please allow for up to 5 business days for processing time. 

There is also a $25.00 charge to complete FMLA forms.  All other forms not completed at the time of the visit will be a $10.00 charge. Please allow for up to 5 business days for completion.

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Commonly used forms for daycare, sports participation, or medications for school are available at our office. These include:

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Daycare Health Form

NC Health Assessment Form (for kindergartners or new students)

NC High School Athletic Association Sports Form

Alamance-Burlington School System Medication Authorization Form

Guilford County Medication Authorization Form

Orange County Medication Authorization Form