Old Dominion Medical Center


Patient Forms

Please click on the links below to download the form of your choice: Please download the appropiate form(s). Please bring in your completed form(s) to your next appointment.

If you have any questions concerning these forms, please feel free to contact us at 703-356-5700 for additional information.

Related Information:

Form Information

Medical Records Release

A medical records release form can be obtained at the front desk, faxed to you, email attachment or downloaded from this website.

Allow 14 business days for medical records to be completed.

The fees for medical records are as follows: $10.00 processing fee+ $.50 per page for the first 50 pages and $0.25 each additional page. Medical records will not be faxed or processed as an email attachment. They can be mailed or picked up at the front desk once payment has been received. [reference Va. Code Section 8.01­413 (2003)]

Form Completion

Form completion fee is $25.00 for a simple form and $45.00 for a complex form, payable at the time of visit. Please be aware not ALL forms can be completed during your visit and you will be asked to allow 3 business days to be completed.