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

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As of Monday, April 17: Masks are optional except for visitors > 2 years who have one or more of the following symptoms: fever, cough, cold, sore throat, vomiting.

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Click the link to download the forms

CAP Patient Basics

Tips for School/ Camp Form Completion
How To Use Patient Portal (Desktop version)
How to Use Patient Portal (Mobile version)
Mask Policy April 17, 2023
Scheduling Appointments using our website
COVID Vaccine 5-11yo FAQ
CAP COVID Vaccine Statement
Lactation Appointment Information

Registration Forms

Financial Policies(opens in a new tab)
Insurance Assignment Authorization(opens in a new tab)
Medical Authorization for Alternate Caregiver(opens in a new tab)
Full Registration (for New Patients or Newborns) is done electronically as part of registration process: please complete Appointment Request

HIPAA Forms

Medical Forms

Learning/Behavior/Emotional Forms

School Forms

Check here for the most common forms needed in the DMV! Capital Area Pediatrics charges $15 per separate form.

Please read our Tips for School/ Camp Form Completion.

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 Universal Health Form for school entrance(opens in a new tab). Part 1 should be completed by you.
Arlington County forms:
Fairfax County forms:
- Medication Authorization Form
- EpiPen Authorization Form
- Inhaler Authorization Form
- Virginia Asthma Action Plan (Required form, needs provider signature)
- FCPS Asthma Action Plan (Supplement to above, needs parent signature only)
Falls Church City Preschool Forms
Loudoun County forms:
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