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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 2-3 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 Forms (2 pages)
  • ​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
  • ​Mental Health appointment forms
Commonwealth of Virginia School Forms:
  • ​Physical Exam Form
  • VHSL Athletic Participation Form​​
Fairfax County School Forms:
  • Medication Authorization Form
  • Epinephrine Authorization Form
  • Inhaler Authorization Form
  • OTHER FAIRFAX COUNTY SCHOOL FORMS
City of Alexandria School Forms:
  • Medical Authorization Form (Pre-K through 8th Grade)
  • Medical Authorization Form (9th through 12th Grade)
  • Epinephrine Authorization Form
  • Inhaler Authorization Form
  • OTHER CITY OF ALEXANDRIA SCHOOL FORMS
Arlington Public Schools Forms:
  • Commonwealth of Virginia School Entrance Health Form
  • Tuberculosis Screening Form
  • OTHER ARLINGTON PUBLIC SCHOOLS FORMS
District of Columbia School Forms:
  • District of Columbia Universal Health Certificate
  • OTHER DISTRICT OF COLUMBIA SCHOOL FORMS
CHILDREN'S MEDICAL ASSOCIATES OF NORTHERN VIRGINIA, P.C.
6303 Little River Turnpike, #300, Alexandria, Virginia 22312   (703) 914-8989   Fax (703) 914-5494
10615 Braddock Road, #200, Fairfax, Virginia 22032   (703) 691-4700   Fax (703) 691-4791
Copyright 2015 Children's Medical Associates of Northern Virginia, P.C. ⎢ Privacy Policy