Patient Forms & Requests:
EMAILING SCHOOL FORMS?
IMPORTANT!
PLEASE make sure that you have completed the following BEFORE EMAILING the entire form in a PDF or Word Format
Name and DOB on ALL pages.
DC school form
VA school form
VHSL sports form
Boy Scouts
COMPLETE PARENT SECTION:
Top box
All of page one
All of pages 1 and 2
All of part B both pages
Forms may be faxed or emailed to our offices at:
Alexandria Office Fax: 703-914-5494; E-mail: forms.alex@cmanva.com
Fairfax Office Fax: 703-691-4791; E-mail: forms.ffx@cmanva.com
There is a $10 fee per completed form.
Please allow 3-5 days for form completion.
CMA Patient Forms:
- Patient Information and Consent Form For All CMA Telemedicine Sessions (pdf)
- Patient Information and Consent Form For All CMA Telemedicine Sessions (word)
- Patient Registration Form
- Statement of Responsibility Form
- CMA Medical Records Release Form
- CMA Notice of Privacy Practices
- Patient Acknowledgement and Consent Form
- Patient Email Consent Form
- Authorization for Treatment of Minors
- Eighteen Year Old’s Responsibility
Commonwealth of Virginia School Forms:
- Physical Exam Form
- VHSL Athletic Participation Form
- Virginia Asthma Action Plan
- FARE Food Allergy Action Plan
Fairfax County School Forms:
- Medication Authorization Form
- Epinephrine Authorization Form
- Inhaler Authorization Form
- OTHER FAIRFAX COUNTY SCHOOL FORMS
City of Alexandria School Forms:
Arlington Public Schools Forms:
District of Columbia School Forms:
- District of Columbia Universal Health Certificate
- District of Columbia Medication Treatment Plan
- OTHER DISTRICT OF COLUMBIA SCHOOL FORMS