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Going to Camp this Summer? Traveling? Need a Health Form?

3 kids with backpack looking at camera

Camp, school and medication forms are to be filled out as much as possible prior to submitting either via Keona (preferred) or by dropping off, mailing or faxing.  (If applicable, please be sure to complete medication section).

Please check all forms to confirm the date last physical is required.  Most forms require a physical be completed withing the last year and patient’s last physical may satisfy requirements and a new physical may not be necessary. Verify and understand your insurance coverage as some insurance companies may not cover a second physical within the same year.

Some common forms can be downloaded on Keona or found on this website under the forms tab.  Once a form is received, it may take between 5 and 7 business days (M-F) for completion.

There is no charge for the first form completed during a well visit.  There is an administrative charge of $15 per each additional form and for any form completed outside of a well-visit.  When available, forms may be expedited and are completed within 48 business hours (M-F) with an administrative charge of $25 and within 24 business hours (M-F) for a fee of $50.

*Forms can be dropped off, mailed or faxed to 703-532-8426.  Due to HIPPA regulations, completed forms may be faxed back upon prior authorization and confirmation that a parent is present to receive the fax.  Forms completed through Keona will be emailed back. You will receive a call for forms dropped off, faxed or mailed, when completed unless prior arrangements have been made.

**Some forms also require that a self Tuberculosis Risk Assessment be checked off.  Checking off this box prior to dropping off the form will greatly speed up processing time. 
Click below for a Tuberculosis Screening Certificate to assist with this process.
Form_Tuberculosis-Screening-Certificate.pdf