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American Kids Care – Pediatric Group

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AMERICAN KIDS CARE, PC

Abdussalam Cheema, MD, FAAP
Amal Gubara, M.D.
Chandanjeet Sidhu, M.D.

Edsal Road Office:
5312 Carolina Place.
Springfield, VA 22151
(703) 914-2723
Hours: M-F 9-5pm Sat/Sun Closed

Springfield / Franconia Office:
6275 Franconia Road.
Alexandria, VA 22310
(703) 971-8686
Hours: M-F 9-5pm Sat/Sun Closed

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PRACTICE FORMS

  • – New Patient Registration Form
  • – Medical History Questionnaire
  • – Notice of Privacy Practices
  • – Record Release form
  • – Covid-19 Vaccine Consent form

ADHD FORMS

  • – NICHQ Vanderbilt Assessment Scale—TEACHER Informant
  • – NICHQ Vanderbilt Assessment Scale—PARENT Informant (2 copies)

FAIRFAX COUNTY SCHOOL FORMS

  • – School Entrance Health Form (Commonwealth of Virginia) (MCH-213)
  • – Epinephrine Authorization (SS/SE-64)
  • – Medication Authorization (SS/SE-63)
  • – Inhaler Authorization (SS/SE-65)
  • – Sports Participation Form Jan 2021

WIC – WOMEN, INFANT & CHILDREN

  • WIC – 395 form 6/21
Copyright American Kids Care, PC 2022 Dr. Cheema
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