Medical Practice Forms

Forms & Policies

TPG Policies

A summary of The Pediatric Group, PC policies. For a more in-depth copy of our policies, procedure, and Newborn parent guide ask you home office for a copy of the TPG Handbook

Pediatric Patient Forms (under 18 years)

New patients and newborns should bring this packet of forms to their first visit at our practice. If you already have children (under 18 year old) who are seen at our practice, please put their names on the forms too.
Please bring a completed copy of these forms to you child's yearly check-up.
Please bring a completed copy of this form to your child's 18 month and 30 month check-ups.
Please have your child fill out these forms and bring it to their yearly check-up.
This form is used for new patients entering the practice or when established patients need to let us know about a change to their Health Insurance or Emergency Contact.
Please send this completed form to your previous medical provider or specialist to have your child's medical records sent to our practice.
Please send this completed form and the records transfer & copy fee to the TPG office where your child is seen. Please allow approximately two weeks for the requested medical records to be copied.
Virginia High School League's Athletic Participation/ Parental Consent/ Physical Examination form is required for high school students to try-out for or participate in VHSL sanctioned sports. In order for our medical providers to complete the physical examination section of the form, the first and second page must be filled out.
Many public and private schools in Virginia require this form to be filled out by your child's doctor prior to enrolling your child in school. **Please fill out the first page of this form prior to having our office complete this form.**
Please fill this form out and print the completed form off.
Please print this form off and ask your child's teacher(s) fill it out. Once they are done, they can fax it back to our practice at (703) 372-5244. We will need this form prior to your Parent-only consult appointment.

Adult Patient Forms (18 years & older)

Registration form for patients 18 years of age and older. On the 2nd and 3rd page of this form, patients chose to give their parents or guardians access to their medical records and medical information.
Please complete these forms and bring them to your yearly check-up.