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  • Providers
    ▼
    • Clayton
      ▼
      • Charles E. Williams, MD
      • Brian K. Harris, MD
      • Scott M. Kahn, MD
      • Jacquelyn McGill, MD
      • Monica Selak, MD
      • Andrew Norris, MD
      • Brittany McCall, FNP-C
      • Megan Wester, PA-C
      • Jenah Manzano, PA-C
      • Rebecca Johnson, FNP-BC
    • Four Oaks
      ▼
      • Stan R. Watson, MD
    • Riverwood
      ▼
      • William Hebda, MD
      • Caroline Lewis, P-A
  • Careers
  • Locations
If you need a medication refill, please contact your pharmacy.

Horizon Family Medicine

Family Health Providers in Johnston County, NC

Horizon Family Medicine
  •  Survey
  • Patient Portal

  • Home
  • Forms
    • New Patient Forms
      • New Patient – Online
      • New Patient – Print
    • Established Patient Forms
      • Established Patient – Online
      • Established Patient – Print
    • Forms for Children
      • Child Initial History
      • Ages & Stages Questionnaires
    • HIPAA/MRR Forms
      • Print HIPAA Privacy Practices
      • Print Medical Records Release
  • Forms
    • New Patients
      • New Patient – Online
      • New Patient – Print
    • Established Patients
      • Established Patient – Online
      • Established Patient – Print
    • Children
      • Initial History
      • Ages & Stages
    • HIPAA/MRR
      • HIPAA Privacy
      • Medical Records Relase
    • Send File
      • Upload File
  • Patients
    • Your Visit
    • Make an Appointment
    • Our Services
    • Insurance
    • Español
    • Patient Visit Survey
    • Coronavirus
  • Resources
    • HFM Resources
    • Community Resources
    • Online Resources
    • Patient Education
    • Specialist Agreements
    • Care Management
    • Interpreter Services
    • Behavioral Health Services
    • TeleMedicine
  • Providers
    • Clayton
        • Charles E. Williams, MD
        • Brian K. Harris, MD
        • Scott M. Kahn, MD
        • Jacquelyn McGill, MD
        • Monica Selak, MD
        • Andrew Norris, MD
        • Brittany McCall, FNP-C
        • Megan Wester, PA-C
        • Jenah Manzano, PA-C
        • Rebecca Johnson, FNP‑C
    • Four Oaks
      • Stan R. Watson, MD
      • Olivia Johnson, MD
      • Hannah Brame, PA-C
    • Riverwood
      • William Hebda, MD
      • Caroline Lewis, PA
  • Providers
    • Clayton
      • Charles E. Williams, MD
      • Brian K. Harris, MD
      • Scott M. Kahn, MD
      • Jacquelyn McGill, MD
      • Monica Selak, MD
      • Andrew Norris, MD
      • Brittany McCall, FNP-C
      • Megan Wester, PA-C
      • Jenah Manzano, PA-C
      • Rebecca Johnson, FNP‑C
    • Four Oaks
      • Stan R. Watson, MD
      • Olivia Johnson, MD
      • Hannah Brame, PA-C
    • Riverwood
      • William Hebda, MD
      • Caroline Lewis, PA
  • Careers
  • Locations
    • Clayton Location
      • 236 Butternut Lane
        Clayton, NC 27520

        Office: (919) 359-1011
        Sat (Acute Care Clinic): (919) 359-0613

        Office Hours:
        Monday-Friday – 8:00 am to 5:30 pm
        Sat (Acute Care Clinic) 9:00 am to 1:00 pm
    • Four Oaks Location
      • 864 Black Creek Road
        Four Oaks, NC 27524


        Office: (919) 963-3148

        Office Hours:
        Monday-Friday – 8:30 am to 5:30 pm
    • Riverwood Location
      • 100 Cunningham Lane
        Clayton, NC 27527


        Office: (919) 359-6016

        Office Hours:
        Monday-Thursday – 8:30 am to 5:00 pm
        Friday - 8:30 am - 4:00 pm
  • Locations
    • Clayton Location
      • 236 Butternut Lane
        Clayton, NC 27520
        Office: (919) 359-1011
        Sat (ACC): (919) 359-0613
        Office Hours:
        Mon-Fri – 8:00 am to 5:30 pm
        Sat (ACC) 9:00 am to 1:00 pm
    • Four Oaks Location
      • 864 Black Creek Road
        Four Oaks, NC 27524


        Office: (919) 963-3148

        Office Hours:
        Mon-Fri – 8:30 am to 5:30 pm
    • Riverwood Location
      • 100 Cunningham Lane
        Clayton, NC 27527


        Office: (919) 359-6016
        Office Hours:
        Mon-Thu – 8:30 am to 5:00 pm  
        Fri - 8:30 am - 4:00 pm

Child Initial History

  • CHILD INITIAL HISTORY FORM

  • If this is your child’s first visit to our practice, please fill out the following Initial History form before your visit. Note: If you would prefer to print a hard copy of the form and bring it with you on your visit, click here.
  • After you have filled out the form, hit the submit button at the bottom of the screen.
    You will be redirected to a page indicating "Your Form Has Been Submitted to HFM."

  • PROVIDER INFORMATION

  • PATIENT INFORMATION

  • Medication NameStrengthHow often?How long have you been on it? 
  • Birth & Past Medical History

  • 11. List previous Hospitalizations and/or Operations:
  • Date of Hospitalization/OperationReason 
  • Feeding (only complete this section if child is less than 1 year old)

  • 14. Solid foods:
  • Health Maintenance

  • Please upload an image of your child's immunization record, or provide a copy to the front desk.
  • Drop files here or
    Accepted file types: jpg, gif, png, Max. file size: 100 MB, Max. files: 1.
    • HABITS

    • SCHOOL HISTORY

    • FAMILY HISTORY

    • 23. Please indicate if ANY family members have had the following:
    • SOCIAL HISTORY

    • 26. What are the parents' occupations?
    • 27. Who provides child care?
    • Safety

    • 28. Does the child ALWAYS:
    • READ & SIGN BELOW

    • I certify that the information provided is correct and complete to the best of my knowledge.
    • Clear Signature
    • MM slash DD slash YYYY

    • This field is for validation purposes and should be left unchanged.

    Clayton Location

    236 Butternut Lane
    Clayton, NC 27520
    Map

    Office: (919) 359-1011
    Sat (Acute Care Clinic): (919) 359-0613

    Office Hours:
    Monday-Friday – 8:00 am to 5:30 pm
    Saturday (Acute Care Clinic) 9:00 am to 1:00 pm

    Four Oaks Location

    864 Black Creek Road
    Four Oaks, NC 27524

    Map

    Office: (919) 963-3148

    Office Hours:
    Monday-Friday – 8:30 am to 5:30 pm

    Riverwood Location

    100 Cunningham Lane
    Clayton, NC 27527
    Map

    Office: (919) 359-6016

    Office Hours:
    Monday-Thursday – 8:30 am to 5:00 pm
    Friday – 8:30 am to 4:00 pm

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