Patient Forms

Forms/Letters

We understand that at times, various forms or letters may be required to assist you with your healthcare needs. These include but not limited to: school forms, sports forms, daycare forms, disability forms, medical leave forms, etc. The staff at Pediatric and Adolescent Medicine will be happy to complete forms and write letters as necessary upon your request. Please complete the portion of the form that requires information from the parent/guardian and then bring it to the office. If you are unsure which form is required, please contact the school, camp, coach, or daycare to ensure that you have the proper one for your child/student We require 72 hours for completion of all forms. If letters are requested that are not related to your child’s healthcare, there may be a fee.

Medical Records

Per HIPAA guidelines, copies of medical records must be requested in writing. To ensure your privacy, a form for release of medical information must be completed prior to receipt of these records. Vaccine records and the last well visits are provided free of charge. For complete records, there is a fee of $20.00 for handling, $0.50 per page for the first fifty (50) pages, and $0.25 per pages afterwards. The law allows Medical Offices thirty (30) days to complete requests for records. However, our medical records department puts forth every effort to respond to these requests in a timely manner.

HIPAA Release Form (English)

Download HIPAA Release Form (English)

HIPAA Release Form (Spanish)

Download HIPAA Release Form (Spanish)

Vaccine Refusal Form

Download Vaccine Refusal Form

NICHQ Vanderbilt Assessment Scales Form (English)

Download NICHQ Vanderbilt Assessment Scales Form (English)

NICHQ Vanderbilt Assessment Scales Form (Spanish)

School Forms

Commonwealth of Virginia School Entrance Health Form

In order for the physicians to complete most school physical forms, your child must have had a physical within the past 12 months.
Download Commonwealth of Virginia School Entrance Health Form

Virginia High School League Form (High School Sports Form)

Your child must have had a physical after May 1st of the current school year. Please complete your portion of the school form and bring it to our office.
Download High School Sports Form

Henrico County Middle School Physical Sports Form

In order for the physicians to complete most school physical forms, your child must have had a physical within the past 12 months.
Download Henrico County Middle School Physical Sports Form

Henrico County School Medication Form

Download Henrico County School Medication Form

Parent and Teacher Vanderbilt Forms for ADHD Evaluation in English

Vanderbilt Assessment Scale (Teacher) Please print and have your child’s teacher complete. Once the form has been completed, please turn it in to your child’s primary physician, along with your parental assessment.
Download Parent and Teacher Vanderbilt Forms for ADHD Evaluation in English