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Clinic Forms & Documents

Immunizations

  • Adult Immunizations Schedule
  • Travel Questionnaire 

General 

  • Patient Registration Form 
  • Assignment of Medical Insurance Benefits
  • North Carolina Minor Consent Law
  • Patient Right of Access

Health Information Exchange 

  • NC HealthConnex Minor Opt Out Form (English)
  • NC HealthConnex Minor Opt Out Form (Spanish)
  • NC HealthConnex Adult Patient Opt Out Form (English)
  • NC HealthConnex Adult Patient Opt Out Form (Spanish)
  • NC HealthConnex Patient Education

Medical Records 

  • Demographic Change Request
  • Release of Information Authorization Form

HIPAA  

  • HIPAA-Onslow County Government Guidelines Notice of Privacy Practices (English)
  • HIPAA-Onslow County Government Guidelines Notice of Privacy Practices (Spanish)


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Contact

  1. Health Department

    612 College Street
    Jacksonville, NC 28540

    Appointments/Information
    Main Line: 910-347-2154

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Helpful Links

  1. World Health Organization: WHO
  2. N.C. Division of Public Health
  3. North Carolina State Center for Health Statistics
  4. CDC Website
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