Patient Forms

REQUIRED FORMS

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Forms are not electronically sent to our office. Please print after completing.

To Book an Appointment Call: (703) 876-0966 option 1

3020 HAMAKER COURT
SUITE 103 FAIRFAX, VA 22031
PHONE: 703-876-0966
FAX: 703-876-1628

Covid-19 Update

Our office is open and we are scheduling appointments at this time.
As you all know, there is a new mandate from the Virginia government to close down all non-essential offices. Under paragraph 5 of the mandate, medical offices are allowed to remain open, so we are continuing to conduct evaluations for now. Please be assured that we are taking all precautions to keep our environment safe for everyone. For the past several weeks, we have been adhering to the guidelines for enhanced sanitizing procedures, and we have re-arranged furniture and changed office/testing procedures so we can maintain at least 6 feet between you and any of our staff. For all in-person appointments, face masks/coverings are being worn by all staff. We are asking that all patients wear a face mask/covering during their appointment. Any patient that does not have their own face mask/covering, one will be provided by our office. In order to ensure the safety of our patients and staff, we are taking the temperature of staff and patients on a daily basis. If it is determined that a staff member or patient has a fever (i.e., temperature in excess of 100 degrees), that person will be asked to go home. In an effort to keep you safe, our office manager will take you immediately from the waiting room into a private room where you can complete the intake paperwork.

You are welcome to bring a family member with you so he/she can participate in the clinical interview, but we ask that family members leave the office after the interview (if possible), so they are not in the waiting room. Also, the deli in our building has closed, so please bring any snacks and drinks that you’d like to have with you. We’re happy to provide water, coffee, and tea.
In order to continue serving patients who would like evaluations but cannot come to the office in person, we are now able to offer telehealth appointments (to include virtual clinical interviews and testing). Please note that this service currently is only covered for Medicare and some private insurers. If you would like to schedule a telehealth visit, please call our scheduling department, 703-876-0966 option 1, to see if your insurance provider is participating.
Our decision to remain open has been a difficult one, but we feel that it’s our ethical obligation to continue providing services to our patients at this point.
If you have any questions or concerns, please feel free to contact us.
We hope you all stay safe and healthy!

COVID-19 Update: Our office is open and we are scheduling appointments at this time.

Patient Forms

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Patient History Form (Fill out electronically and print)

Patient History Form (Print and fill out by hand)

Authorization for Release of Healthcare Information

Notice of Privacy Practices

Patient Demographic Information

Release Form from NAF

TeleHealth Consent Form

To Book an Appointment Call: (703) 876-0966 option 1

Covid-19 Update