Patient Forms & Requests:
FAXING SCHOOL FORMS?
IMPORTANT!
PLEASE make sure that you have completed the following BEFORE FAXING
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 to our offices at:
Alexandria Office Fax: 703-914-5494
Fairfax Office Fax: 703-691-4791
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:
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