Forms

Fairfax County School Forms

FPA Allergy Testing Forms

Medical Record Forms

Consent Forms

Screening Forms

ADHD Forms

Blank forms will not be accepted. We will only accept forms that have the patient’s name and medical history portion filled out.

Form completion is usually 3-5 business days. We receive a large number of form request each week. To avoid rush processing fee, please submit your forms early.

 

Due to Health Insurance Portability and Accountability Act (HIPAA) regulations, forms will be released to parents only. We will mail the forms to the home address on file at your request. Please provide us with a stamped and self-addressed envelope for this purpose.

Many forms require the information to be based on an examination completed within 12 months of the date the form is completed or may require specific evaluations that were not performed at the routine physical, i.e. sport vitals, asthma/allergy treatment plans. An additional office visit may be required.

There is no charge for forms submitted at time of the child’s well check appointment. Please plan ahead and have your forms ready at the well check.

  • $10 per form (outside of well child exam)
  • $30 for “Rush Service” form (completed with one business day)

Please note that the front staff does not have the authority to alter, reduce or waive charges. Fees are collected at time of form pick-up.

Request must be in writing with a release of information authorization by the parent or legal guardian Written request must include the purpose/content of the letter as well as the title, name, and address to whom the letter is intended. Letters to consulting physicians/hospitals will not incur a fee. All other letters will incur a $25 fee. Please include a self addressed stamped envelope if you would like a copy of the letter mailed to you.