Patient Info & Forms | Capital Area Pediatrics - Ashburn, VA

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Thank you for wearing your mask and adhering to our 1 child, 1 parent rule!

Please continue to use our touchless check-in to avoid crowding in our lobby!

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Click the link to download the forms

CAP Patient Basics

Registration Forms

HIPAA Forms

Privacy Practice Notice(opens in a new tab)
Nondiscrimination Statement(opens in a new tab)
Under 18 Release of Privacy Notice(opens in a new tab)
Over 18 Release of Privacy Notice(opens in a new tab)
Medical Records Release Form(opens in a new tab) (Medical Records to be Transferred to Another Practice)

Medical Forms

Learning/Behavior/Emotional Forms

School Forms

Check here for commonly needed forms for Virginia and Washington DC. Capital Area Pediatrics charges $10.00 per school form.

Virginia School Entrance Form(opens in a new tab). Page 1 should be completed by you. Please complete this TB questionnaire for the provider to complete your form.
VHSL Sports Form (High School Sports). (opens in a new tab)Please print and bring all 4 pages to your appointment. Page 2 must be completed prior to the visit. The provider must review page 2 before completing the form.
Maryland State Health Inventory Form. Part 1 should be completed by you.
Washington DC Health Form for school entrance(opens in a new tab). Part 1 should be completed by you.
Arlington County forms:
- Medication Administration Form(opens in a new tab)
- TB Risk Screen Form
Alexandria City Public School Forms
Fairfax County forms:
Falls Church City Preschool Forms
Loudoun Country forms:
- TB clearance form
- Medication forms(opens in a new tab)
Prince William County Medication Authorization Form
Washington DC Medication Authorization Form(opens in a new tab)
Boy Scouts Form(opens in a new tab). Please fill out Parts A and B and bring to your appointment. The provider must complete Part C.

Medical Forms