2605 Blue Ridge Road, Suite 100 Raleigh, NC 27607(919) 881-9009

Forms, Patient Survey & Quality of Care Reports


If you have a newborn joining our practice, click the link below to print out the paperwork we will require at your first visit prior to being seen.  

Interested in joining our practice? Please print out and complete the following forms, include a copy or your insurance policy, and submit the documents to our office with a copy of your previous medical records. Once we have you registered as a patient, we will be able to schedule your first appointment. 

Is your child an existing patient and you need to update your information? Please complete and send in an updated Patient Registraion Form if you recently had an insurance or contact information change. Some changes may be made directly through the portal and will require a signed confirmation at your next visit. 

Do you need to request records? If your child is a current patient under the age of 18, most of their records may be available to you through our patient portal. If you wish to use the portal to access records, you do not need to complete a form. The link to log in is at the bottom of this page.

If the records you require are not available on the portal, please submit a completed medical release to our office. Fees may apply. 



Click on our Patient & Family Survey to provide us with valuable feedback about our practice.

We appreciate and value your responses, which are anonymous. We use your feedback to identify opportunities to improve our practice and the care we provide for your children.

Have you visited an urgent care recently? If you have a few minutes, please take time to complete our Urgent Care Survey.

If you would like to review results of our Patient and Family Survey, please open the links below: 


Quality improvement initiatives are continously underway at Carolina Kids Pediatrics. Below you will find a link to the most recent quality improvement summary report for 2020-2021. We will generate new reports in future years. As they become available, we will post the most recent report here. If you are interested in helping to shape future quality improvement initiatives and would like to serve on our patient advisory committee, please contact us by patient portal or by calling our office.

Quality Improvement Initiative 2020-21


In order to view or print forms from this site, you will need Adobe Acrobat Reader installed. Click here to download it.

Nondiscrimination Statement and Nondiscrimination Notice

Assistance Services for Limited English Proficiency Patients