Patient Forms

Before your appointment with us, you may quickly and conveniently access patient forms from our practice.

By downloading these forms and bringing them with you to your appointment, you may be registered efficiently and seen in a timely fashion.

Access Secure Online Patient Forms

Your request will be processed within 24 hours, during normal business hours. If you do not receive confirmation of your request within 48 hours, please contact our office by phone at 703-330-3939 (Manassas) or 571-222-2520 (Haymarket).

The Patient Pre-Registration Form (secure on-line) enables us to enter you in our system with the minimal required information. We request that you also download, print and complete our New Patient Registration Packet which requests additional information that is required to complete your child’s profile and bring these forms to your first appointment along with a current photo ID and your insurance card.

Patient Pre-Registration

Patient Pre-Registration 

New Patients Only
If your child is a new patient of Pediatricare of Northern Virginia, fill out our Patient Pre-Registration Form

Request Appointment

Request Appointment

Online Bill Pay

Pay Your Bill

To pay your bill online.

Download Patient Forms

To view the forms listed below, you will need Adobe Reader. You may download Adobe Reader for free at Please bring your completed forms with you to our office at the time of your visit.

If you need to make any updates to your address or phone numbers please fill out a new Patient Registration form and fax it to our Manassas office at 703-331-0959.

If this is your First Appointment, you will need to bring the completed New Patient Registration Packet with you. Please also review our Financial Policy for helpful information.

To have your records sent to our office from another physician’s office, please download our Medical Record Request Form. It may also be used if you need to have your records from our office copied.

School Forms

Below you will find some of the most commonly used forms provided by our local schools. Please print a copy and bring it with you to your appointment and we will gladly complete them for you within 24 to 48 hours.

Call us at (703) 330-3939

COVID-19: How We Keep YOU Safe

We have always been committed to ensuring your child’s health and well-being regardless of what the world throws at us as a “village” Exceptional circumstances require innovative processes to keep your family safe. It’s our commitment to you and our community. Here’s how we honor that commitment

Curbside Check-in

Schedule your appt, tell us you want curbside check-in. Let us do the navigation for you. Let us know you are here, proceed into the building to our suite and you will be met by a staff member upon arrival and immediately escorted to your personal exam room in our office bypassing the normal check in process. Our families love it!

Schedule a visit

Video Appointments

No apps to download, No special processes that make life difficult and it’s HIPAA compliant and easy to schedule. We would love to tell you more. It’s a fantastic way to have your child’s health concerns addressed in the privacy of your home.

Learn about telehealth

Split Schedule

Well-child checks ONLY in the morning bright and early is the perfect time to make sure your child is getting the preventative care they need!

Schedule your child’s well check

****Reduced traffic flow in the common areas of the building and our office****
Several practices in the building have consolidated locations out of our building which means there is a significant decrease in activity in the hallways. The Fitness Center is also closed! People are practicing strict social distancing too. Plenty of parking, non-crowded hallways, and elevators where people don’t jump in with one another. It’s a win/win.

****We take care of ourselves so we can care for you****
We have always followed scientifically established protocols to ensure that our facility is clean and our staff is healthy, now more than ever, rest assured that our processes for infection control are superior and our commitment to minimizing risk is unwavering. We are happy to report that the entire staff has remained healthy during this pandemic because of the exceptional commitment we have, as part of your village, to adhering to CDC guidelines both at work and during our time off.

We miss you, we miss the kids and we are ALWAYS here for you and committed to keeping you safe.