Forms

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.

Forms

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.

Registration Forms

Family Demographic Form

HIPAA Acknowledgement Form

Release of Information Form

Telehealth Consent Waiver

Auto-Pay Authorization

18yr+ HIPAA Release

Nutrition Assessment Form

Flu Vaccination Forms

Flu Vaccine Waiver

Flu Vaccine Waiver

Medical Records

Request records from your old pediatrician to give to us

Do you need medical records from us?

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

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.