Forms
These forms are Adobe .pdf forms. Please download your form and fill it out and bring it to your appointment. You may fax the form to our office at 703 476-7126. Please do not email the forms as the e-mail is not secure. Some of the files are fillable Adobe files. You may fill in the blanks on your computer and then print out the form to send it. Need Adobe reader --> click here
Office forms
Patient Registration -- demographic and insurance information. New patients and current patients who wish to report new information.
Medical History -- information about your personal and family medical history, medications, surgeries and allergies (coming soon)
School forms
Sports physicals -- forms for the Virginia Athletic League pre-participation exam. Please print out; fill out pages 1 and 2 and bring in all pages for the exam. Please have immunization records with you.
School entrance physical forms -- for students starting kindergarden or moving into the area; please make sure you have immunization records; students cannot start school until all immunizations are accounted for
Link for an Adobe fillable school entrance exam form
State law (Ref. Code of Virginia § 22.1-270) requires that your child is immunized and receives a comprehensive physical examination before entering public
kindergarten or elementary school. The parent or guardian completes this page (Part I) of the form. The Medical Provider completes Part II and Part III of the
form. This form must be completed no longer than one year before your child’s entry into school.
Returning students interim health form -- filled out for students returning to school after summer break to update health history
Medication Authorization -- must be filled in if your student needs to have medication given at school (Fairfax County) for Loudoun County
Inhaler Use at School -- must be filled out to be able to use an asthma inhaler at school (Fairfax County) for Loudoun County
Epi Pen use -- forms for Fairfax and Loudoun