Advanced Pediatrics

100 East Street SE, Suite 301

Vienna, VA 22180
(P) 703.938.5555

(F) 703.319.8580


A number of forms normally requested are listed below.  For school and camp forms there is a $10 fee. 

For a copy of the medical record there is a $20 fee per child, maximum of $50 per family.

Please complete all parental portions of forms prior to the visit.   This allows the medical provider to review this information when completing the requested forms.  

In addition, please hand any forms to the front desk staff when checking in.  Do not hand forms to the medical staff during the visit itself.  This both slows down the process of the visit and completion of the form.


Medical Records

Medical Records Release Request

Use this form to request that your previous practice release your medical records and vaccine history to us so that we can better provide care to your child.

Medical Records Request​

Use this form if you are moving or leaving our practice and would like copies of your medical and vaccine records for your own future use.

School Forms

ADHD Assessment

Behavioral Consult