FORMS

We are happy to complete forms for your child if your child is up to date with their age appropriate physical exam. Some organizations do require that your child have an exam within a year of starting the camp. It states this on the form. There is a fee to complete forms.


To process your request, please follow the instructions below:


  *   If you need a Virginia School Form, call our Forms Line and leave a message (703-435-3636 OPTION 7).  
  *   For all other forms,  fax, email  or drop the form off at our office.  The email address for forms is admin@rtcpeds.com<mailto:admin@rtcpeds.com>. 

 

IMPORTANT Please be sure to include BOTH the name of the patient and your phone contact information,  in case we need to reach out and ask any questions AND complete the entire parent/student portion BEFORE sending it in.  We cannot email back from this email address.  Any form requests sent in without information identifying who the patient is or do not have the completed information will not be processed. 
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Most forms will be completed in 2-3 business days.  If you do not hear from us after 3 business days, please call the office 703-435-3636 OPTION 3 to speak with our nurses. If you need form(s) completed before 72 hours there is a RUSH FEE.

Well Patient Forms


Ages 2 weeks - 6 months: Patient Registration Form PostPartum Depression Questionaire Credit Card on File Consent Form Ages 1-12 years: Patient Registration Form TB, Water, Cholesterol and Lead Screening Questionaire Credit Card on File Consent Form * 18 months & 2 year visits ONLY: MChat Form GIRLS (Ages 13-17 years): Patient Registration Form Adolescent Questionaire Parent of Adolescent Questionaire TB, Water, Cholesterol and Lead Screening Questionaire Credit Card on File Consent Form BOYS (Ages 14-17 years): Patient Registration Form Adolescent Questionaire Parent of Adolescent Questionaire TB, Water, Cholesterol and Lead Screening Questionaire Credit Card on File Consent Form Age 18 years: Patient Registration Form TB, Water, Cholesterol and Lead Screening Questionaire Adolescent Questionaire for Teens Adolescent Questionaire for Parents Credit Card on File Consent Form Teen Consent Other: HIPPA (Health Insurance Portability & Accountability Act)




School & Sports Forms


State of Virginia School Physical Form Virginia High School Sports Form Fairfax County Medication Form Fairfax County Inhaler Authorization Form Loudon County Medication Form Loudon County Ashtma Action Form *PLEASE NOTE THERE IS A $20 FEE FOR EACH FORM COMPLETED, max of $60. There is no charge If the school or sports forms are brought to the visit, however there is still a charge for all other forms requested. **An additional $15 will be added for each form requested to be completed within 24 hours.





Some forms may require Adobe Acrobat Reader. Click the Adobe logo to download.