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LSFP

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Proud Member of Loudoun Medical Group

Forms

Before your first visit, we encourage you to print the pdf forms below to fill out and bring to your appointment along with prior medical records and immunization records.

Patient Portal Login


Printable Forms:

New Patients – Adult (18+)
  • Authorization to Disclose Health Information (HIPAA)
  • Receipt of Notice of Privacy Practices Acknowledgement
  • Medical Records Release Authorization
  • Health History
  • Patient Information
  • Patient Information (Spanish)
  • Consent for Health Information Exchange
  • Financial Policy
New Patients – Pediatrics
  • Authorization to Disclose Health Information (HIPAA)
  • Receipt of Notice of Privacy Practices Acknowledgement
  • Medical Records Release Authorization
  • Patient Information
  • Patient Information (Spanish)
  • Pediatrics – New Patient Questionnaire
  • Financial Policy
Other
  • Pre-Vaccine Screening Form
  • Adult Preventive Health Visit Policy Acknowledgement Form
  • Patient Health Questionnaire 
  • Consent to Participate in Telemedicine
  • Medicare Shared Savings Program – Accountable Care Organizations

Congratulations to our practitioners! LSFP has been named Best of Loudoun… AGAIN!

Get to Know LSFP

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You can reach the on-call provider after hours by calling toll free: (866)427-6121.

If you are having a true emergency after hours, visit LMG Cornwall Urgent Care. They have access to all LMG medical records

Patient Portal

  • Lansdowne
    (703) 724-7530
  • Ashburn
    (571) 252-7353
  • Leesburg
    (703) 777-1612
  • Purcellville
    (540) 338-9896
  • Lovettsville
    (540) 579-0500
  • Stone Springs
    (703) 957-1255

Disclaimer: This Website Does Not Provide Medical Advice

The information, including but not limited to, text, graphics, images and other material contained on this website are for informational purposes only. The purpose of this website is to promote broad consumer understanding and knowledge of various health topics. It is not intended to be a substitute for professional medical advice, diagnosis or treatment. Always seek the advice of your physician or other qualified health care provider with any questions you may have regarding a medical condition or treatment and before undertaking a new health care regimen, and never disregard professional medical advice or delay in seeking it because of something you have read on this website.

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