New Patient Form

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VACCINE REFUSAL / DELAY FORM

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I have been informed of the CDC and AAP recommended vaccines and understand the risks of delaying or refusing immunizations.
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ADHD STIMULANT MEDICATION AGREEMENT

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I understand stimulant medications are controlled substances and agree to:
• Take medication only as prescribed.
• No early refills except documented
circumstances.
• Attend required follow-up visits.
• Not share or misuse medication.
• Comply with monitoring including CSRS review and possible drug screening.
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ADOLESCENT CONFIDENTIALITY AGREEMENT

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North Carolina law allows minors to consent to certain confidential services. Confidential care includes reproductive health, STI testing, mental health, and substance use services. Confidentiality may be broken if there is risk of harm or abuse.
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CONSENT FOR EAR PIERCING

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I consent to ear piercing and understand risks including pain, bleeding, swelling, and infection.
Aftercare instructions provided:
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CREDIT CARD ON FILE AUTHORIZATION

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Authorized for:
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PHOTO / MEDIA CONSENT

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I authorize Brightside Care to use photographs for:
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AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION

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Information to be released:
Purpose:
Expiration: 12 months from signature unless revoked.
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