Patient forms

Select any of the links below to download important forms for your visit:

• Health Care Power of Attorney
• Health Care Power of Attorney (Spanish)
• Living Will
• Living Will (Spanish)
• Authorization To Disclose Health Or Billing Information
• Authorization To Disclose Health Or Billing Information (Spanish)
• Patient Information/Consent To Treat
• Communicating Your Health Information
• Personal Data

Consent to treat a minor

• Patient Information/Consent To Treat

Advance Directives

What is a living will?

In North Carolina, a living will is a document that tells others that you want to die a natural death if you are terminally and incurably sick or in a persistent vegetative state from which you will not recover. In a living will, you can direct your doctor not to use extraordinary means that would delay your dying.

Example: Using a breathing machine (respirator or ventilator), or to stop such treatments if they have been started. You can also direct your doctor not to begin or to stop giving you food and water through a tube (artificial nutrition or hydration).

What is a healthcare power of attorney (healthcare agent)?

In North Carolina, you can name a person to make medical care decisions for you, including mental health treatment decisions, if you later become unable to decide yourself. This person is called your healthcare agent. In the legal document you name who you want your agent to be. You can say what medical treatments you would or would not want. Your agent then knows what choices you would make.

Where can I get more information?

Ask our front desk receptionist.

Other forms

Please visit North Carolina Department of the Secretary of State website to download following forms:

• Advance Instruction for Mental Health Treatment
• Organ Donor
• Advance Health Care Directive Registry
• Revocation Form