Sensory-Friendly Program at Inova Loudoun ER: Parental Intake Form

Changes to telemedicine coverage for Medicare patients

Effective October 1, 2025, several telemedicine flexibilities for patients have expired. For patients insured by a government program, this impacts any upcoming virtual visits with your healthcare provider.

Learn more for next steps

Current Patient Information
Motivators/Likes
Stressors/Dislikes
Sensory Challenges
Previous Medical Experience
Complete

Patient Information

Thank you for choosing the Children's Emergency Room at Inova Loudoun Hospital to care for your child. Please fill out this form to help us learn how to best meet the needs of your child.

Questions? Call us at 703-858-6048

Patient First Name

Patient Last Name

Developmental/Cognitive Level

Communication Style

Communication Devices

Best way to approach your child?

Signs of distress

Signs of pain

Calming strategies used at home

Ability to transition to new environments

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