Forms & Policies

Forms and Policies

For your convenience, we have provided links to many useful office and school forms in PDF format. If you need a free copy of Adobe Reader, please visit

Office Forms

Please fill out these four forms and bring them to your first visit.

Additional forms:

School Forms


School Forms

Health forms are required by many organizations including schools, daycare, camps, and school athletic departments. Health forms that are brought to a well child examination will be completed at that office visit. When forms are required at other times, they will be completed within 7-10 business days. There is a $10 charge for each form.

Prescription Refills

Please call your pharmacy and have them Fax a refill request to our office at 703-522-0495. This allows your physician to verify that your current prescription is appropriate and refilled properly.

ADHD medication prescriptions must be handwritten by a physician. Please call or Fax our office to request ADHD medication refills.

Overnight Telephone Calls

For urgent medical issues and questions between 10 pm and 8 am, the answering service will initially connect you to a pediatric telephone nursing service. Please note that this after-hours nursing service is not covered by most insurance plans. There will be a charge of 25 dollars to cover the telephone nursing service.

Missed Well Child Appointments

Please notify us if you cannot make a well child appointment at least 24 hours in advance.  Without advanced notice, there will be a fee for missed well child appointments.

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