 |
|
|
|
|
|
|
|
|
|
|
|
|
|
 |
|
||||||||||||
 |
 |
 |
 |
 |
 |
 |
 |
 |
 |
 |
 |
 |
|
 |
 |
 |
 |
 |
 |
|
|||||||
• Patient Forms
INOVA Fairfax Craniofacial Clinic referrals, please review information contained here
New Patient Electronic Registration and Submission
There are a few key forms that can be completed electronically using Adobe pdf readers (downloadable for free) and securely submitted to our office electronically using the submission form below. Optionally, one can just print out the forms after typing the info in. Keep in mind that though you may electronically sign the forms, our office policy requires you to co-sign the forms by hand when you arrive for your appointment. These forms include:
|
DOWNLOAD: New Patient Registration Forms (4 pages) IF you are seeing us for allergies, complete this form |
Download, fill out all fields, and save pdf document.
You have the option of printing the forms out and faxing to us at 540-347-5224 (the SAFEST way to submit). Please remember to physically cosign all signature boxes.
Alternatively, you have the option of electronically submitting them as attachments using the submission form below (not as safe even if encrypted). If you are concerned about security due to absence of a browser padlock, click here for alternative secure web form. Even if you submit electronically, please print the forms out and bring them with you to your appointment (just in case).
For all other forms (listed below), please download, complete by hand, and either bring them with you to your first appointment or fax (540-347-5224) the paperwork and any other relevant reports (sleep study, MRI, CT, etc) to us >24 hours prior to your appointment.
Please arrive at least 15 minutes before your appointment in order for us to copy your insurance cards, collect any co-payment, and to make your file. Be aware that some insurance companies require a referral authorization from your primary care doctor in order to be seen by a specialist. Make sure this authorization is sent to us by your doctor PRIOR to your appointment!
|
|
Other Forms That Need to Be Completed By Hand If you have no health insurance, complete this form and bring with you IF you desire allergy testing, read & sign this form IF you are seeing us for dizziness, complete this form |
Remember to bring the following items to expedite your first visit with us and PLEASE give these reports immediately to the check-in person so we can get them scanned into our medical records (prevents check-out delays).
- All the above forms
- List of all your medications
- CT and/or MRI scans (BOTH the actual films and report)
- Sleep study reports
- BRING your actual health insurance card
- Referral authorization sent to our office PRIOR to your appointment (if applicable)
If you need to obtain, send, or transfer medical records from another office, please print out our release form.
Forms for audiology & hearing aid services are here depending on the problem.
As an FYI, Fauquier Hospital also offers online pre-registration for any studies (CT and MRI scans), tests (bloodwork), and procedures (surgical) that may be performed there.
Any information provided on this Web site should not be considered medical advice or a substitute for a consultation with a physician. If you have a medical problem, contact your local physician for diagnosis and treatment. Advertisements present are clearly labelled and in no way support the website or influence the contents.
