Practice Forms and Policies
New Patient Forms
Virginia State School Forms
Parents need to complete page1 and sign. Pages 2-4 are for the office. Health Information Form/Comprehensive Physical Examination Report/Certification of Immunization
VHSL Physical Evaluation Form (ATHLETIC PARTICIPATION/PARENTAL CONSENT/EVALUATION FORM)
Pages 1,2, and 4 must be completed by parent, child and signed. Page 3 is for provider/front office.
Authorization for Medication Administration
Parents need to fill out Student’s Information, section 2 and 3. Section 1 is for the provider/front-office and section 4 is for School
Allergy Action Plan, Physician’s Order (EpiPen)
Parents would need to fill out the top portion Student Information and Asthma History/severe allergies on the first page
Asthma Action Plan (Physician's Order)
Parents would just fill out the student information section only. The rest is for the provider/front-office
Records Requests
Behavioral Health Forms
Vaccine Policy
As medical professionals, we feel very strongly that vaccinating children on schedule with currently available vaccines is absolutely the right thing to do for all children and young adults. We are making you aware of these facts not to scare you or coerce you, but to emphasize the importance of vaccinating your child. We are more than willing to discuss any questions you may have about vaccines, but do require all new patients to our practice to adhere to the vaccination schedule endorsed by the American Academy of Pediatrics (AAP)
- We firmly believe in the effectiveness of vaccines to prevent serious illness and to save lives.
- We firmly believe in the safety of our vaccines.
- We firmly believe that all children and young adults should receive all of the recommended vaccines according to the schedule published by the Centers for Disease Control and Prevention (CDC) and the American Academy of Pediatrics (AAP).
- We firmly believe, based on all available literature, evidence, and current studies, that vaccines do not cause autism or other developmental disabilities.
- We firmly believe that thimerosal, a preservative that has been in vaccines for decades and remains in some vaccines, does not cause autism or other developmental disabilities.
- We firmly believe that vaccinating children and young adults may be the single most important health promoting intervention we perform as health care providers, and that you can support as parents/caregivers.
The recommended vaccines and the schedule of administration are the results of years and years of scientific study and data-gathering on millions of children by thousands of our brightest scientists and physicians.
The vaccine campaign is truly a victim of its own success. It is precisely because vaccines are so effective at preventing illness that we are even discussing whether or not they should be given. Because of vaccines, many of you have never seen a child with polio, tetanus, whooping cough, bacterial meningitis, or even chickenpox, or known a friend or family member whose child died of one of these diseases. Such success can make us complacent or even lazy about vaccinating. But such an attitude, if it becomes widespread, can only lead to tragic results.
Over the past several years, many people in Europe have chosen not to vaccinate their children with the MMR (measles, mumps, rubella) vaccine after publication of an unfounded suspicion (later retracted) that the vaccine caused autism. As a result of under-immunization, there have been small outbreaks of measles and several deaths from complications of measles in Europe over the past several years. The United States experienced a record number of measles cases during 2019, with 1282 cases from 31 states reported to CDC's National Center for Immunization and Respiratory Diseases (NCIRD). This is the greatest number of cases since measles elimination was documented in the U.S. in 2000.
Furthermore, we firmly believe that by not vaccinating your child, you are taking selfish advantage of thousands of others who do vaccinate their children, which decreases the likelihood that a child will contract one of these diseases. We feel such an attitude to be self-centered and unacceptable. Even delaying or “breaking up the vaccines” to give one or two at a time over additional visits goes against expert recommendations, is not supported by any scientific data, can lead to unnecessary delays and errors, and can put your child, other children, and adults at risk for serious illness (or even death). It is therefore against our medical advice as professionals at Penguin Pediatrics.
Privacy Policy HIPAA
PRIVACY STATEMENT
We are committed to protecting your privacy and providing a safe online experience. This Privacy Statement applies to our Practice's website and governs our data collection and usage practices. By using this website, you consent to the data practices described in this Privacy Statement.
Collection of your Personal Information
This Practice collects personally identifiable information provided by you, such as your e-mail address, name, home or work address or telephone number. This Practice also collects anonymous demographic information, which is not unique to you, such as your ZIP code, age, gender, preferences, interests and favorites. There is also information about your computer hardware and software that is automatically collected by this website. This information can include: your IP address, browser type, domain names, access times and referring website addresses. This information is used for the operation of the service, to maintain quality of the service, and to provide general statistics regarding use of this website. Please keep in mind that if you directly disclose personally identifiable information or personally sensitive data through public message boards, this information may be collected and used by others. This Practice encourages you to review the privacy statements of websites you choose to link to from the website so that you can understand how those websites collect, use and share your information. This Practice is not responsible for the privacy statements or other content on any other websites.
Use of your Personal Information
This Practice collects and uses your personal information to operate the website and deliver the services you have requested. This Practice also uses your personally identifiable information to inform you of other products or services available from this Practice and its affiliates. This Practice may also contact you via surveys to conduct research about your opinion of current services or of potential new services that may be offered. This Practice does not sell, rent or lease its customer lists to third parties. This Practice may share data with trusted partners to help us perform statistical analysis, send you email or postal mail, provide customer support, or arrange for deliveries. All such third parties are prohibited from using your personal information except to provide these services and they are required to maintain the confidentiality of your information. This Practice does not use or disclose sensitive personal information, such as race, religion, or political affiliations, without your explicit consent. This Practice will disclose your personal information, without notice, only if required to do so by law.
Use of Cookies
The website uses "cookies" to help this Practice personalize your online experience. A cookie is a text file that is placed on your hard disk by a webpage server. Cookies cannot be used to run programs or deliver viruses to your computer. Cookies are uniquely assigned to you, and can only be read by a web server in the domain that issued the cookie to you.
Security of your Personal Information
This Practice secures your personal information from unauthorized access, use or disclosure. This Practice secures the personally identifiable information you provide on computer servers in a controlled, secure environment, protected from unauthorized access, use or disclosure. When personal information (such as a credit card number) is transmitted to other websites, it is protected through the use of encryption, such as the Secure Socket Layer (SSL) protocol.
Changes to this Statement
This Practice will occasionally update this Privacy Statement to reflect company and customer feedback. We encourage you to periodically review this Privacy Statement to be informed of how this Practice is protecting your information.
Contact Information
Please contact us by phone at 571-223-2229 or by mail at 44095 Pipeline Plaza, Suite 410, Ashburn, VA 20147.
