After-Hours Care Appointments

New Patient Registration

Submitted online, no printing required.

Step 3

Disclosures and Consents, Patient Financial Agreement  This form requires your signature. Use your mouse or complete the form using a touch screen device (smart phone, tablet) for the signature.

Touch Screen Forms

Submitted online, no printing required.

The forms below require your electronic signature. Complete and sign using a touch screen device (smart phone, tablet, touch screen computer, or a laptop/desktop with a mouse) for the signature.

Please note: Duke University Medical Records does not accept electronic signatures on release of medical records forms. Please use the printed release form below under “Other Forms” and return to the office by fax, mail, or in-person. All other medical records can be released with an electronic signature.

Behavioral Wellness Counseling Services

Below two forms require your signature. Use your mouse or complete the forms using a touch screen device (smart phone, tablet) for the signature.

Avance Care’s policy related to
completing above WCPSS forms:

Patients requiring a form completed by our office for school, camp, sports, pre-school, medication administration forms, or any other form that requires a physician’s signature, if brought in conjunction with your child’s well/physical exam visit, the office will complete the form at no additional cost to the parent. Please ensure that you complete all components of that form prior to your child’s arrival at our office. Avance Care encourages parents to bring the form with them as we may not have the most up to date required form for your child at hand.

Should the necessary forms not be presented by the parent at the time of your child’s well/ physical exam visit and it is brought in or mailed to our office for completion after their well/physical exam visit, you will be subjected to a $5.00 administrative fee for each form/each child that will be due upon Avance Care’s completion of that form. If you are requesting that our office mail your child’s form back, you will need to send payment along with that form. Please be aware that this $5.00 fee is not covered by your medical insurance policy.