Click the link to download the forms
CAP Patient Basics
- Tips for School/ Camp Form Completion
- How To Use Patient Portal (Desktop version)
- How to Use Patient Portal (Mobile version)
- Lactation Appointment Information
- Scheduling Appointments using our website
- CAP COVID Vaccine Statement
Registration Forms
- Financial Policies(opens in a new tab)
- Insurance Assignment Authorization(opens in a new tab)
- Medical Authorization for Alternate Caregiver(opens in a new tab)
- Full Registration (for New Patients or Newborns) is done electronically as part of registration process: please complete Appointment Request
Medical Forms
- Asthma Control Test age 4-11 years(opens in a new tab)
- Asthma Control Test 4-11 años (Español)
- Asthma Control Test age 12 years and up
- Asthma Control Test 12 años y más (Español)
- Community Resources Arlington County
- Community Resources Fairfax County
- Community Resources Loudoun County
- Community Resources Prince William County
Learning/Behavior/Emotional Forms
- Learning Behavior Intake Packet age 4-11(opens in a new tab)
- Learning Behavior Intake Packet age 12-19(opens in a new tab)
- Parent Vanderbilt Initial
- Parent Vanderbilt Follow Up
- Teacher Vanderbilt Initial(opens in a new tab)
- Teacher Vanderbilt Follow Up
- Patient Safety Plan / Agreement(opens in a new tab)
- PHQ-9: Modified for Teens(opens in a new tab)
- Youth Pediatric Symptom Checklist-17 (Y PSC-17)(opens in a new tab)
- Screening for Child Anxiety Related Disorders (Parent)(opens in a new tab)
- Screening for Child Anxiety Related Disorders (Child)(opens in a new tab)
- GAD-7 (Anxiety)
- Children's Eating Attitude Test (ChEAT)
- Eating Attitudes Test (EAT)
School Forms
Check here for the most common forms needed in the DMV! Capital Area Pediatrics charges $15 per separate form.
Please read our Tips for School/ Camp Form Completion.
- Virginia School Entrance Form(opens in a new tab). Page 1 should be completed by you. Please complete this TB questionnaire for the provider to complete your form.
- VHSL Sports Form (High School Sports). (opens in a new tab)Please print and bring all 4 pages to your appointment. Page 2 must be completed prior to the visit. The provider must review page 2 before completing the form.
- Maryland State Health Inventory Form. Part 1 should be completed by you.
- Washington DC Universal Health Form for school entrance(opens in a new tab). Part 1 should be completed by you.
- Arlington County forms:
- Fairfax County forms:
- Medication Authorization Form
- EpiPen Authorization Form
- Inhaler Authorization Form
- Virginia Asthma Action Plan (Required form, needs provider signature)
- FCPS Asthma Action Plan (Supplement to above, needs parent signature only)
- Falls Church City School Forms
- Loudoun County forms:
- Prince William County School Forms
- Washington DC Medication Authorization Form(opens in a new tab)
- Boy Scouts Form(opens in a new tab). Please fill out Parts A and B and bring to your appointment. The provider must complete Part C.
Medical Forms
- Vaccines Service Auth(opens in a new tab)
- Evaluation & Management(opens in a new tab)
- Under 28 Day Preventative Services(opens in a new tab)
- 1 Mo. Service Auth(opens in a new tab)
- 2 Mo. Service Auth(opens in a new tab)
- 4 Mo. Service Auth(opens in a new tab)
- 6 Mo. Service Auth(opens in a new tab)
- 9 Mo. Service Auth(opens in a new tab)
- 12 Mo. Service Auth(opens in a new tab)
- 15 Mo. Service Auth(opens in a new tab)
- 18 Mo. Service Auth(opens in a new tab)
- 24 Mo. Service Auth(opens in a new tab)
- 30 Mo. Service Auth(opens in a new tab)
- 3 Yr. Service Auth(opens in a new tab)
- 4 Yr. Service Auth(opens in a new tab)
- 5 Yr. Service Auth(opens in a new tab)
- 6-8 Yr. Service Auth(opens in a new tab)
- 9 Yr. Service Auth(opens in a new tab)
- 10 Yr. Service Auth(opens in a new tab)
- 11 Yr. Service Auth(opens in a new tab)
- 12 Yr. Service Auth(opens in a new tab)
- 13 Yr. Service Auth(opens in a new tab)
- 14 Yr. Service Auth(opens in a new tab)
- 15 Yr. Service Auth(opens in a new tab)
- 1(opens in a new tab)6-17 Yr. Service Auth(opens in a new tab)
- 18 Yr. Service Auth(opens in a new tab)
- Sports / Camp Clearance(opens in a new tab)
- Travel Consult Service(opens in a new tab)
- Lactation Consult(opens in a new tab)
- Lactation Supplies(opens in a new tab)
- AsthmaManagementServiceAuth(opens in a new tab)
- After Hours Phone Call Charges