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 $10 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 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 50 dollars fee for missed well child appointments.