Kids First Pediatrics


Providing Comprehensive Care for
Newborns 
to
Young Adults
Matthew D. Samarel, MD, FAAP

Elissa R. Levine, MD, FAAP

Namrata P. Wheeler, MD, FAAP

Jennifer W. Lassiter, MD, FAAP

Ankita Modi, MD, FAAP

8169 Ardrey Kell Road
Charlotte, NC 28277

Phone 704-542-5540
Fax 704-542-5227

Forms and Records

Enrollment Form: Please feel free to download the enrollment form (you'll need Adobe Reader) for Kids First Pediatrics Patient(s). You may enroll more than one child on the same form. Please feel free to fax us the form at (704) 542-5227, bring it to your first scheduled appointment or mail it to us at:

Kids First Pediatrics
8169 Ardrey Kell Road
Charlotte, NC 28277

Policies and Consent: Please feel free to download the Policies and Consent form (you'll need Adobe Reader) for Kids First Pediatrics Patient(s).

Transferring Records:  Please feel free to download the records transfer form (you'll need Adobe Reader) for Kids First Pediatrics Patient(s). Please feel free to fax us the form at (704) 542-5227, bring it to your first scheduled appointment or mail it to us at:

Kids First Pediatrics
8169 Ardrey Kell Road
Charlotte, NC 28277

Forms: Any form that is completed during a well visit will be done at no charge. Other forms will be assessed a $10.00 fee and be completed in 3 business days, or when necessary it will be $20.00 and it will be rushed to be completed in 24 hours. This includes, but is not limited to: school & daycare enrollment forms, athletic participation forms, and camp registration forms.
There will NOT be a fee for the completion of required Medication Consent Forms, Asthma Action Plans, and Kindergarten Assessment forms.

Medical Records:  Your child’s medical records at Kids First Pediatrics are always available for you. There is a $20.00 administration fee per record, and please give 48 hours notification of your request. This request must be in writing, by letter or by form. We offer an acceptable form for you to download and print. (you'll need Adobe Reader)
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