(703) 993-2831 Fairfax Clinic & After-Hours Nurse Advice

Forms

Immunization Forms

Immunization Record Form

Mason Certificate of Medical Exemption for Immunizations Requirements

COVID Vaccine/Testing Form (if you are not able to locate documentation, your healthcare provider can complete the form)

Medical Records Request Forms

Release of Health Records FROM Mason Form

Request for Release of Medical Records TO Mason

ADD/ADHD Forms

ADD/ADHD Diagnosis and Treatment Documentation Form

ADD/ADHD Cardiovascular Screening Form

ADD/ADHD Medication Contract

Allergy and Travel Clinic Forms

Allergy Clinic Student Employee Agreement Form

Travel Clinic Assessment Form

Feedback and Appeal Forms

Online feedback form

Immunization late fee appeal form

No show fee appeal form

SHS transcription fee appeal form

Patient portal error report form

Safer Sex Condom Request Form

Safer Sex Condom Request Form

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