Forms
- If you would like to sign up for FollowMyHealth please contact the office and ask for a patient portal invite or fill out the form below.
RVA Pediatrics requires a pre-paid fee of $10.00* 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.
*Effective May 1, 2023, the form fee will be $10 per form.
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.
If you are requesting a patient portal invite via our online form, please allow up to 72 hours to receive the invite link.
Parents requesting a portal invite on behalf of their children (under 18 years old) will be sent "proxy" patient portal invitations.
Patients 18 and older will need to call the office to request individual access
PATIENT FORMS
Medical Records Request/Transfer (PDF)
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. Effective May 1, 2023, there will be a fee of $30 for all medical record transfers from our office.
Notice of Privacy Practices (PDF)
This notice describes how medical information about you may be used and disclosed and how you can get access to this information.
Patient COVID Vaccine Questionnaire
Please print and complete this form prior to your COVID vaccine appointment. Bring the completed form to your scheduled appointment.
SCHOOL FORMS
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.
Commonwealth of Virginia School Entrance Health Form (PDF)
In order for the physicians to complete most school physical forms, your child must have had a physical within the past 12 months.
Concussion Policy Henrico County Schools (PDF)
Virginia High School League 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.
Hanover County Middle School Sports Physical Form (PDF)
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.
Henrico County Middle School Sports Physical Form (PDF)
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.
Permission to Administer Medication Form (Henrico)
Please complete the necessary information and bring to office.
ASSESSMENT FORMS
Depression Screening Questionnaire (PDF)
NICHQ Vanderbilt Assessment Scale: Teacher (PDF)
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.
NICHQ Vanderbilt Assessment Scale: PARENT (PDF)
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.
Permission to Discuss Personal Health Information: PHI (PDF)
ONLINE FORMS
