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.
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.