Wilmington Pediatrics
About Us
Seasonal Influenza
Contact Us
Office Policies
Privacy Notice
Patient Portal
Mass Immunization Information System
MHQP Patient Experience Survey
Links for parents
Adolescent Privacy Practices and consent form
Behavioral Screens
Vanderbilt Follow Up Assessment
Wilmington Pediatrics

Adolescent Privacy Practices and Consent form




 Once a pediatric patient turns 13 years old, an important shift occurs in the interactions with your pediatrician.  We welcome you to discuss these policies with your child’s doctor or another staff member.

 Starting at the first encounter with your pediatrician (in many cases, which occurred in the newborn nursery), the primary collaborative aim has been to help to raise healthy children, so they become healthy adults.  Each phase of a child’s development requires different strategies to achieve this goal.  Working together in the adolescent years will require two important components:

  •  confidentiality between child and doctor
  •  shifting responsibility for health decisions from  parent/guardian to child


 Providing good health care requires honesty between patient and doctor.  Teens are often willing to discuss important topics openly, only if they are assured of confidentiality.  State laws recognize this concept and protect teens by making it possible for an adolescent to seek care for certain conditions without parental consent.  We will abide by those laws and honor the confidence of our patients.

 The following is a partial list of topics that we will NOT discuss with a parent/guardian without first having the teen’s permission: sexual activity/contraception, drug/alcohol use, and mental health issues.

 There are certain situations that allow a pediatrician to overrule these confidentiality protections and notify a parent/guardian, even without a teen’s permission.  Basically, we share information when we believe the adolescent poses a threat to harm him/herself or to harm another person.

 Let us finally state that, in general, we do not encourage teens to keep secrets from their parents/guardians.  When a teen patient is involved in certain risky behaviors, we recognize the valuable role the family can play in helping the adolescent reduce or discontinue unhealthy practices.  In short, you – as a parent/guardian – have trusted your pediatrician’s judgment for many years, and we are asking you to trust our judgment in managing sensitive information during the coming years, remembering that we remain united in our goal of helping your child grow to be as healthy as possible.


 In only a few short years, your child will be 18, at which time he/she will need to be prepared to operate more independently in regards to many aspects of life, including health care.

 It is the policy of our practice to see patients up until their 19th birthday.  Practically, this means that most patients remain with us here through high school graduation. This means that sometime between now and then, your child will need to begin to plan for where he/she will receive primary care after that point.

 We expect parents, patients, pediatricians and staff to work together, so that the next few years are a gradual transition: where the responsibility of seeking and obtaining medical care shifts from parent/guardian to patient.

 Here are a few concrete ways that this shift in responsibility will be implemented:

 Beginning with a patient’s 13-year old well visit, the log-in information for our patient portal website will be held by the patient, not the parent.

  1. Individual steps in this transition will be discussed between the pediatrician and patient at each well visit between the ages of 13-18.  Specific suggestions will include:
    1. Adolescents should be familiar with their own medications.  They should be aware when refills are needed.
    2. High school juniors/seniors should begin identifying adult primary care providers, so they develop a sense of where they will go next.
    3. Once a patient turns 18 years old, he/she will have sole access to his/her health information.  For example, unless the patient provides written permission to the parent/guardian, only the patient will be able to obtain medical information (including test results).

When you come into our office for your child's 12 year well child check, you will receive the above information. 

Your child will receive and be asked to sign the agreement below.  Please feel free to discuss this with your child's primary care physician if you have any questions or concerns.




I, Dr. ________________________________ (the doctor), want you to be able to be honest with me about your concerns and your health.  I want you to understand that when we talk about things that have to do with sex and drugs and your feelings, it is confidential.  This means that what we talk about is just between you and me and that other people, including your parents, will not find out about it unless you want them to know.  One exception to this is if I am concerned someone has abused or hurt you.  Another exception is if I am concerned you are at serious risk of harm or are planning to or behaving as though you may hurt yourself or someone else.  In these situations, I would have to talk to other adults, but I would talk to you first so we could figure out whom we should talk to and the best way to handle it.



I, _____________________________________ (the patient), agree to talk with my doctor about anything I am concerned about and to be honest when answering questions and discussing my health.



Signed on date _________________: