The ChildHealth Center, PA

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COVID-19 Vaccine Info

What's New

Practitioners

Kenneth V. Summer

Laura J. Luckadoo

Tatyana V. Golub

Angela M. Frierson

Anna Shamsnia

Denise E. Niehues

Seth A. Abel

Misty S Cline

Tonya P. Manus

Ann M. Adams

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Pay Bill Online!

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Pediatric Care from Birth Through College Age

Form Completion Policy
 
Forms that you need completed for your child are completed at no extra charge when you bring the form to your child's well check up.  Medical forms provided at other times will be subject to a $10 fee, whether the form is mailed, faxed, or picked up in person.  Please allow up to 5 business days for all forms to be completed.

Common Office Forms

The following group of files
should be completed by all new patients:

Document
Registration Form
Document
Medial Records Release TO TCC
Document
Medial Records Release FROM TCC
Document
Medical History for Newborns
Document
Medical History Form Beyond Newborn Age
Please download and print the appropriate following files
that apply to your child's particular needs or well visit,
and complete at home ahead of your child's visit.
By bringing the completed form to the visit
you will save time! 

Document
Sports Preparticipation History
Document
Birth to 5 month old well visit history
Document
6 to 11 month old well visit history
Document
12-36 month old well visit history
Document
4 to 12 year old well visit history
Document
13+ year old well visit history
Document
NC Health Information Exchange Opt Out--English
Document
NC Health Information Exchange Opt Out--Spanish
Last updated April 8, 2025
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