Patient Forms
Patient Forms
Forms can be completed online through the patient portal or you can print them from our website and bring them with you to your appointment.
Authorization for Release of Medical Information
Allows patients to authorize the disclosure of their health information to a designated individual, company, agency, or facility.
Authorization and Consent for Treatment
All patients must provide their consent for treatment, communications (calls, emails, and text messaging), and agreement of financial responsibility.
Preferred Contacts
Patients are encouraged to complete and return the Preferred Contacts Form but it is not required.
Virtual Visit Policy
This policy describes the process for the documentation, maintenance, and transmission of information using virtual visit technology.
Office Policies
Financial Policy
This form advises patients of their complete financial responsibility for all medical services received without regard to insurance eligibility or coverage determinations.
Notice of Privacy Practices
Describes how health information about you (as a patient of this Care Center) may be used and disclosed, and how you can get access to your individually identifiable health information. Please review this notice carefully.
Hospital Affiliations
Inova Fair Oaks Hospital
Inova Fairfax Hospital
Inova Loudoun Hospital
Reston Hospital Center
Stone Spring Hospital
Winchester Hospital Center
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Other Forms
Hospital Affiliations
Inova Fair Oaks Hospital
Inova Fairfax Hospital
Inova Loudoun Hospital
Reston Hospital Center
Stone Spring Hospital
Winchester Hospital Center
