Effective April 1, 2014, we require a pre-paid fee of $5.00 per form to complete forms (except if form completed during appointment). This includes, but is not limited to; school forms, sports forms, daycare forms, disability forms, medical leave forms. We require 72 hours for completion of all forms.

In addition, if we have to retrieve your child’s chart from storage for any reason, there will be a pre-paid fee of $25. To receive storage records within 24 hours, there will be an additional fee of $20 to expedite any requests for charts from storage.

Please complete your portion of the form and bring it to our office. We are able to mail the forms back to you as long as you have provided a self-addressed stamped envelope. We are unable to fax forms to you. We do not keep copies of completed forms. All forms not picked up within 30 days will be discarded. If you are not sure which form is needed, please contact your school, camp, or athletic department for clarification.

 

Commonwealth of Virginia School Entrance Health Form In order for the physicians to complete most school physical forms, your child must have had a physical within the past 12 months.

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Sports Physical Form (High School Only) For participation in sports, your child must have had a physical after May 1st of the current school year. Please complete your portion of the school form and bring it to our office.

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Henrico County Middle School Sports Physical For participation in sports, your child must have had a physical after May 1st of the current school year. Please complete your portion of the school form and bring it to our office.

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Hanover County Middle School Sports Physical For participation in sports, your child must have had a physical after May 1st of the current school year. Please complete your portion of the school form and bring it to our office.

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Chesterfield County Sports Physical For participation in sports, your child must have had a physical after May 1st of the current school year. Please complete your portion of the school form and bring it to our office.

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Vanderbilt Assessment Scale (Teacher) Please print and have your child’s teacher complete. Once the form has been completed, please turn it in to your child’s primary physician, along with your parental assessment.

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Vanderbilt Assessment Scale (Parent) Please print and complete. Once the form has been completed, turn it in to your child’s primary physician, along with your child’s teacher assessment.

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Screening questionnaire for FluMist Please print this form, fill it out and bring it with you to your appointment. For more information regarding the FluMist, please click here.

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Concussion Policy Henrico County Schools

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Collegiate School Only 7-12 grades require this form. 6th grade only requires a copy of the immunization record.

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Permission to administer medication (Henrico) Please complete the necessary information and bring to office.

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Records request/transfer If you are transferring from our office to another practice, please print this form and return it to us in person or fax to 804-754-0880. Once received, we will have the records transferred within 7-10 business days. If you are transferring from another practice to us, please print this and send it to your previous physician’s office.

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