n our  efforts  to  spend more  time  with  you during  your  visit,  we  encourage  you  to  please  log  into  the Portal  and complete  the  appropriate  visit  forms  for  your  child prior  to  your  arrival.  If  you  are  unable to  do  so,  please  arrive  20-30  minutes  prior  to  your  scheduled appointment  time  to  fill  out  the electronic  forms  at  the  office: 1.  All  NEW patients,  including  newborns   •  “New Patient Intake”  form  plus  additional forms  as  applicable  below 2.    All  sick  visits   •  “Pre-visit  Updates”  form  only 3.    Sport   Physicals  –  This  is  for children  who  need  a  sport  physical but  have  had  a regular WCC within  the  last  12  months.   If  the  child  has  NOT  had  a  WCC  within  the  last  12  months,  they  will need  to  complete  the  age  appropriate  WCC  forms  below •  “Pre-visit  Updates”  form   •  Sports Physical  form 4.    Well  Child Check-  Ups Newborn well  check   •  Well check  Questionnaire •  Newborn to age 1 Additional  Questions 2  week   •  Well check  Questionnaire •  Newborn to age 1 Additional  Questions 1  month •  Well check  questionnaire •  Newborn to age 1 Additional  Questions 2  month •  Well check  Questionnaire •  Newborn to age 1 Additional  Questions 4  month •  Well check  Questionnaire •  Newborn to age 1 Additional  Questions 6  month •  Well check  Questionnaire •  Newborn to age 1 Additional  Questions •  Lead screen 9  month •  Well check  Questionnaire •  Newborn to age 1 Additional  Questions 12  month •  Well check  Questionnaire •  Newborn to age 1 Additional  Questions •  Tuberculosis •  Lead screen 15  month •  Well check  Questionnaire •  1 year to 19 year  Additional  Questions 18  month •  Well check  Questionnaire •  1 year to  19 year  Additional  Questions •  MCHAT 2  year •  Well check  Questionnaire •  1 year to  19-year  Additional  Questions •  Tuberculosis  screen •  Lead screen 2  ½  year  (not  always  covered by  insurance,  please  check  with your  insurance  company) •  Well check  Questionnaire •  1 year to  19-year  Additional  Questions 3  year •  Well check  Questionnaire •  1 year to  19-year  Additional  Questions •  Tuberculosis  screen •  Lead screen 4  year •  Well check  Questionnaire •  1 year to  19-year  Additional  Questions •  Tuberculosis  screen •  Lead screen 5  year •    Well check Questionnaire •  1 year to  19-year  Additional  Questions •  Tuberculosis  screen •  Lead screen 6  year •    Well check Questionnaire •  1 year to  19-year  Additional  Questions •  Tuberculosis  screen •  Lead screen  7  year •  Well check  Questionnaire •  1year to  19-year  Additional  Questions •  Tuberculosis  screen 8  year •  Well check  Questionnaire •  1year to  19-year  Additional  Questions •  Tuberculosis  screen 9  year •  Well check  Questionnaire •  1 year to  19-year  Additional  Questions •  Tuberculosis  screen 10  year •  Well check  Questionnaire •  1 year to  19-year  Additional  Questions •  Tuberculosis  screen 11  year •  Well check  Questionnaire •  1 year to  19-year  Additional  Questions •  Tuberculosis  screen •  Girls 11yr  and  up  Additional  Questions 12  year •  Well check  Questionnaire •  1 year to  19-year  Additional  Questions •  Tuberculosis  screen •  Girls  11yr  and  up  Additional  Questions 13  year •  Well child  Questionnaire •  1 year to  19-year  Additional  Questions •  Tuberculosis  screen •  Teen Questionnaire •  Girls  11  year  and  up  Additional  Questions 14  year •  Well child  Questionnaire •  1 year to  19-year  Additional  Questions •  Tuberculosis  screen •  Teen Questionnaire •  Girls 11  year  and  up  Additional  Questions 15  year •  Well child  Questionnaire •  1 year to  19-year  Additional  Questions •  Tuberculosis  screen •  Teen Questionnaire •  Girls 11  year  and  up  Additional  Questions •  NURSE TO ASK:  PHQ2,  Tobacco  Control  Questions  and  Audit  C  if Alcohol use  + 16  year •  Well child  Questionnaire •  1 year to  19-year  Additional  Questions •  Tuberculosis  screen •  Teen Questionnaire •  Girls 11  year  and  up  Additional  Questions 17  year •  Well child  Questionnaire •  1 year to  19-year  Additional  Questions •  Tuberculosis  screen •  Teen Questionnaire •  Girls 11  year  and  up  Additional  Questions 18  year •  Well child  Questionnaire •  1 year to 19-year Additional  Questions •  Tuberculosis  screen •  Teen Questionnaire •  Girls 11  year  and  up  Additional  Questions

823 South King Suite F, Leesburg, VA 20175

46165 Westlake Drive Suite 210, Sterling, VA 20165

Located in Leesburg and Sterling, VA & proudly serving Loudoun County and surrounding areas

Phone: 703.777.5222

17 Sylvia Lane New Hyde Park,
New York 11040
Phone: 1.800.123.4567

Fax: 1.800.123.4566