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Phone & Fax Numbers for All Locations
Phone: 703-924-2100 | Fax: 703-922-6067

Inova Healthplex Office
6355 Walker Lane, Ste 401, Alexandria, VA 22310
Potomac Yard Office
3600 S. Glebe Rd., Ste 150, Arlington, VA 22202
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703-924-2100
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Patient Forms

Weighing a baby at Pediatric Associates of Alexandria

We have forms available online for you to view and print. Completing necessary paperwork prior to your child’s visit helps quicken the check-in process. Please take a minute to complete all applicable areas on the form prior to dropping it off or mailing it to our office.

We will complete most child care, publicprivate school and college medical forms within three business days. *There is a $10.00 fee for each form requested. Please include this payment with your form(s) to expedite the process.

Forms Packets

Individual Forms

Individual Forms for Dr. Shropshire's Patients (Behavioral Health)

School & Sports Forms


Screening Forms

Vanderbilt ADHD Forms

Initial Assessment Form (complete prior to initial ADHD appointment)

Follow-up Forms (complete after treatment started)

Anxiety Related Disorders

Autism

Depression

Parent Survey


Medical Records Release Policy

When requesting your child's medical records, a Medical Records Request Form must be completed and returned to Pediatrics Associates of Alexandria. Once the completed form has been received, our office will contact the parent or guardian informing them of their cost for processing a copy of their records. Payment is typically made by credit card over the phone with no additional fee. Please allow approximately two weeks from receipt of the payment for the records to be processed and received.

Specialists Referrals Policy

Pediatric Associates of Alexandria asks that you submit requests for referrals at least five business days prior to your scheduled appointment with your child's specialist. Please provide: the child's full name, date of birth, parent or guardian's name, contact phone number, name of insurance, date of appointment, specialist's complete name, office phone number, and diagnosis or reason for office visit. Once the referral is complete, the parent or guardian will be notified by phone that it is ready for pick-up at our office. Referrals will not be faxed.

It is the responsibility of the parent or guardian to submit a referral request at least five business days prior to the child's appointment with the specialist. Only under extreme emergency circumstances will same day referrals be approved and completed. Referrals cannot be back dated, and in most cases, your insurance requires 24 to 48 hours notice to approve (giving us authorization).