Your health and safety is always our top priority. Call your physician if you think you have the coronavirus or call 877-9NOVANT if you don’t have one. Learn more »

Visitor restrictions, masking and other safety measures are in effect. Learn more »

Show Navigation
Kernersville Family Medicine
Home / Patient Tools / Patient Forms

Patient forms

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

Consent to treat a minor

What is needed in order to treat a minor?

Medical care may be given to a child with the consent of a parent or legal guardian in writing. Please fill out the Patient Information/Consent to Treat form above.

Advance directives

Our practice supports patient's rights to make decisions abut their medical care and treatment, especially in situations where they cannot make their wishes known. Review information available about Advance Directives, Living Wills and Durable Power of Attorney.

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.



Monday to Friday
7 a.m. to 5 p.m.