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Patient Forms

New Patient Form

  • New Patient Registration Form (English)
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  • New Patient Registration Form (Spanish)
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Regular Forms

  • Medical History Questionnaire
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  • Notice of Privacy Practices
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  • Record Release form
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  • Covid-19 Vaccine Consent form
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School Forms

  • NICHQ Vanderbilt Assessment Scale—TEACHER Informant
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  • NICHQ Vanderbilt Assessment Scale—PARENT Informant (2 copies)
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Fairfax County School Forms

  • School Entrance Health Form (Commonwealth of Virginia) (MCH-213)
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  • Epinephrine Authorization (SS/SE-64)
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  • Medication Authorization (SS/SE-63)
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  • Inhaler Authorization (SS/SE-65)
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  • Sports Participation Form Jan 2022
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WIC - Women, Infant & Childern

  • WIC – 395 form 6/22
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Providing your family with the best care of Springfield VA

Committed to help kids of all ages and their families achieve optimal physical and mental health
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  • Support: cheema@cheemamd.com
  • Address: 5312 Carolina Pl. Springfield VA 22151

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  • Email: info@americankc.com
  • Ph: (703) 914-2723
  • Address: 5312 Carolina Place
  • Springfield, VA 22151
  • Office hours
  • Monday – Friday: 9am -5pm
  • Saturday - Sunday: Closed
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    5312 Carolina Pl. Springfield
    VA 22151