Patient Forms

To fill out the PDF forms below please download the latest free Adobe Acrobat Reader application.

• Patient Registration & Information Change Form: Please fill this form out and bring it with you on your first visit or if any information has changed such as address, phone numbers, insurance provider, etc.
• 18 + Patient Registration & Information Change Form: Please fill this form out and bring it with you on your first visit or if any information has changed such as address, phone numbers, insurance provider, etc.
• History Questionnaire
• HIPAA Form in English
• HIPAA Form in Spanish
• Authorization to Obtain Medical Care and Treatment: You may authorize others to obtain medical care and treatment for your child/children by filling out this form.
• Over 18- Authorization to Release Information: If you are over 18 years old please fill out this form if you wish us to share your information with your parents and/or someone else you designate.
• Records Release Form: If you need an immunization record please call the office where your child is normally seen. If you need a copy of your child’s medical records from this office please fill out this form, indicate which office you would like to pick them up at and then fax the form to our medical records department at 703-444-0386. Please call our medical records department to be sure it has been received. Allow at least 15 business days for your records to be ready, our office will call you when they are ready for pick up.
• For Loudoun County school forms please see our Loudoun School Forms page.