Forms

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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. 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.

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Registration Forms

Lifetime Consent Form

HIPAA Acknowledgement Form

Telehealth Consent Waiver

Auto-Pay Authorization

18yr+ HIPAA Release

Preventative Form

Medical Records

Request Records From Your Old Pediatrician to Give to Advanced Pediatrics

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.

Transfer Medical Records From Advanced Pediatrics

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

Release of Information

Use this form to request copies of your child’s medical records, transfer records to another provider, or request records from a previous pediatrician to be sent to our office.

School Forms

Commonwealth of Virginia School Health Form

VHSL Sports Physical Form

Medication Authorization Form

Epinephrine Authorization Form

Food Allergy & Anaphylaxis Emergency Care Plan

VA Asthma Action Plan Form

VA Department of Health School Health Forms

Epilepsy Seizure Action Plan