"The best interest of the patient is the only interest to be considered." - Dr. William J. Mayo
Executive Physical Examination Medical Questionnaire
Please complete the following information so that the staff of Fair Lakes Urgent
Care Center will be able to make an appropriate recommendation as to the type of
executive physical evaluation that is best tailored to your medical needs.
Our dedicated team of physicians will review your medical questionnaire form,
provide a free assessment of your health care needs and make appropriate
recommendations.
If interested in having an Executive Physical Examination, print this form (PDF
File (printer friendly version), or as Microsoft Word document version)
and either mail or fax it to us and one of our staff will contact you within
24 hours of receiving the form.
Tel. (703) 222-3555
Fax: (703) 222-8430
Our postal address:
Fair Lakes Urgent Care Center.
12713 Shops Lane
Fairfax, VA 22033
USA
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Updated 07/25/00