Annandale Family Medicine Edward Friedler, M.D., Mercedes Quintos-Gomez, M.D., Sharayu Sawant, M.D.

Patient Registration

If you have not been seen since August 1, 2005, we will need to update your patient registration and insurance information. Please print the patient registration form below, fill it out, and bring it to the office with your insurance card and co-pay.

• Patient Registration Form (pdf)

Medical Information Release

To have your medical records transferred, use this form. You will be billed for this service.

• Medical Information Release Form (pdf)

HIPAA

• Patient Rights (pdf)
• Patient Summary (pdf)

Fairfax County Public Schools

• Administration of Medication (SS/SE-66) 
• Emergency Care Information for Students (SS/SE-3) 
• Epinephrine Authorization (SS/SE-64) 
• Inhaler Authorization (SS/SE-65) 
• Medication Authorization (SS/SE-63) 
• Physical Examination Form (VHSL) Athletic Participation /Parental Consent/

Additional Forms

For Handicap Parking Placard or Plate (Virginia) (PDF)