For Patients & Families

For Patients & Families

For a full listing of our phone numbers, see the directory below. You can also view medical records and manage your appointments using our patient portal.


Forms

For your convenience, we have provided downloadable forms for each of our divisions below. Additional information may be found on the division pages.

Pediatric Lung and Allergy Center

To learn more about these forms, review our PLAC: Planning Your Visit page.

New Patient Forms

  • Registration Form English | Spanish
  • Notice of Privacy Practices English | Spanish
  • Consent to Treatment/Acknowledgement of Receipt of Notice of Privacy Practices for parent/guardian of a minor child English | Spanish
  • Consent to Treatment/Acknowledgement of Receipt of Privacy Practices for adult patients English | Spanish
  • Financial Responsibility Statement English | Spanish
  • New Allergy Patient Intake Form English | Spanish
  • New Allergy Patient Instructions English
  • Telemedicine Session Patient Authorization and Consent Form English | Spanish

If you are being seen for Immunotherapy (Allergy Shots), you may also complete the following forms:

  • Immunotherapy (Allergy Shots) Consent Form English
  • Immunotherapy (Allergy Shots) Serum Renewal Consent Form English

Pediatric Surgical Group

To learn more about these forms, review PSG’s Planning Your Visit page.

New Patient Forms

  • Registration Form English | Spanish
  • Financial Responsibility Statement English | Spanish
  • Notice of Privacy Practices English | Spanish
  • Consent to Treatment/Acknowledgement of Receipt of Notice of Privacy Practices (for parent/guardian of a minor child) English | Spanish
  • Consent to Treatment/Acknowledgement of Receipt of Privacy Practices (for adult patients) English | Spanish
  • Medical Permission Form English | Spanish
  • Telemedicine Session Patient Authorization and Consent Form English | Spanish

Pediatric and Adolescent Sleep Center

To learn more about these forms, review our Planning Your Visit to PASC page.

New Patient Forms

Established Patient Forms

Additional Consent Forms

  • Medical Permission Form English | Spanish
  • Authorization to Use and/or Disclose Protected Health Information Form with instructions English | Spanish
  • Request to Review and/or Obtain a Copy Protected Health Information (PHI) Form with instructions English | Spanish
  • Telemedicine Session Patient Authorization and Consent Form English | Spanish

Sleep Study FAQs

Sleep Study FAQs – English | Spanish

Sleep Study Only Forms

  • Patient Registration Form English | Spanish
  • Notice of Privacy Practices English | Spanish
  • Consent to Treatment/Acknowledgement of Receipt of Notice of Privacy Practices (for parent/guardian of a minor child) English | Spanish
  • Consent to Treatment/Acknowledgement of Receipt of Privacy Practices (for adult patients) English | Spanish
  • Sleep Log (Please fill this out 2 weeks prior to your child’s sleep study.) English | Spanish

 

COVID-19 Update

We are closely following the most up-to-date announcements and information on the known cases of Novel Coronavirus (COVID-19). Because this information is always changing, we will be monitoring all updates from the  Centers for Disease Control and Virginia Department of Health. 

If you are experiencing cold or flu symptoms, please make sure to contact us via phone prior to your appointment. You may also contact us for any additional questions by calling our offices.

Here are a few additional resources as well: 

Virginia Department of Health

Centers for Disease Control

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