Child's Contact & Medical Information

Child's Medical History
Is Child Allergic to Anything?
Previous Hospitalizations or Surgeries
Is your child experiencing any mental or emotional challenges?
Should child's activites be limited?

A PHYSICAL EXAMINATION must be completed and signed by a licensed physician, their authorized agent currently approved by the N.C. Board of Medical Examiners (or a comparable board from bordering states), a certified nurse practitioner, or a public health nurse meeting DHHS standards for EPSDT program. Please upload a signed and dated examination and child's IMMUNIZATION RECORD.

Upload Physical & Immunization

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