Forms

HIPAA Form

The Health Insurance Portability and Accountability Act (HIPAA) was enacted by the U.S. Congress in 1996 in part, to help people keep their information private. As you complete this form, keep in mind the importance of naming any adult who you would like to bring your child to the doctor or have access to your child’s medical records.

download the HIPAA form for patients 18 and older

download the HIPAA form for patients 17 and younger

Personal Information Form

Please print out this form, complete it, and bring it to your first appointment.

download the personal information form for patients 18 and older

download the personal information form for patients 17 and younger

MCHAT form

If your child is coming for a 2-year-old checkup visit, you can print this form and complete prior to the
appointment.

download the MCHAT form

Tuberculosis Risk Factors
If your child is coming for an annual well-child checkup, you can print this form and complete prior to the
appointment.

download the tuberculosis risk factors form

School, Camp, and Daycare Forms

Please print out the following form and complete the parent sections before your appointment. In order to complete a school, camp or daycare form, we require that your child has had a complete physical within the last 12 months. Camp forms are available from your camp. Our office requires that you complete the parent section of the form prior to our physicians signing the form.
download the form

Sports Forms

Most school districts require a physician’s evaluation before trying out for school sports. Virginia High School League (VHSL) requires a separate examination for each school year completed between May 1 of the current year through June 30 of the following year. Please print a copy of the VHSL form, or bring a completed copy of your school’s form to your appointment. Although every effort will be made to complete the forms during your visit, it may take us as long as one week. Our office requires that you complete the parent section of the form prior to our physicians signing the form.
download the form