Camp, School and Sports Forms
Camp, school and medication forms are to be filled out as much as possible prior to submitting either via Keona (preferred) or dropping off* at the office for completion. (If applicable, please be sure to complete medication section). Please also ensure that your child has had a physical exam within 12 months of form request. 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 3 and 5 business days for completion. Forms completed through Keona will be emailed back. You will recieve a call for forms dropped off* when completed unless prior arrangements have been made. There is an administrative charge of $15 per form. Expedited forms are completed within 48 hours with an administrative charge of $25 and same day 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.
Please check all forms to confirm the date last physical is required. Patient’s last physical may satisfy requirements and a new physical may not be necessary. Verify and understand your coverage as some insurance companies may not cover a second physical within the same year.
**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.
https://www.northernvirginiapediatrics.com/PDF/fillable/Form_Tuberculosis-Screening-Certificate.pdf
