Forms

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

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
• Anaphylaxis Action Plan Form
• OTHER FAIRFAX COUNTY SCHOOL FORMS

City of Alexandria School Forms:

• Medication Authorization Form
• OTHER CITY OF ALEXANDRIA SCHOOL FORMS

Arlington Public Schools Forms:

• Tuberculosis Screening Form
• OTHER 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

Maryland School Forms:

• Maryland School Health Inventory