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 www.adobe.com.
Please fill out these four forms and bring them to your first visit.
- Office Policies
- Authorization for Release of Medical Records
- M-CHAT- Modified Checklist for Autism in Toddlers
- ADHD Symptom Rating Scales
- Commonwealth of Virginia School Entrance Health Form
- Virginia High School Athletic Participation Health Form
- District of Columbia School Entrance Health Form
- Authorization for Administration of Medicine at School – Arlington
- Asthma Action Care Plan – Arlington
- Severe Allergy Action Plan – Arlington
- Tuberculosis Screening Form – Arlington
- Acute Concussion Evaluation Care Plan
- Food Allergy & Anaphylaxis Emergency Care Plan
- Authorization for Administration of Medicine at School – Fairfax
- Authorization for Epinephrine at School – Fairfax
- Authorization for Inhaler Use at School – Fairfax
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 $15 ( as of Jan 11, 2021) charge for each form.
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.
Please call 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 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 $50 fee for missed well child appointments.
Sports Physical Appointments
Virginia High School League (VHSL) guidelines require completion of a sports pre-participation physical between May 1st of the current calendar year through June 30th of the upcoming year. If your child has had a well-child exam prior to May 1st of this year, he/she will need to come into the office for a sports physical with updated medical history and physical examination prior to completion of the sports clearance form. Unfortunately, most insurers do not cover the cost of this additional visit, required by VHSL as of March 2013. We charge a self-pay flat rate of $75.00; this will include VHSL physical form, which is collected at the time of your appointment.
Letter of Medical Necessity
We ask parent or legal guardian to submit a written example of the letter requested describing the medical necessity including the title, name and address to whom the letter is intended. Once the letter has been reviewed it is up to the provider’s discretion to generate and sign the letter. There will be a charge of $25. Letters to consulting physician/hospital will not incur the fee.