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INOVA Fairfax Craniofacial Clinic referrals, please review information contained here

New Patient Registration, Information, and Other Forms

Download, print, and fill out all of the following forms and bring them with you to your first appointment. If able to, faxing (540-347-5224) the paperwork and any other relevant reports (sleep study, MRI, CT, etc) to us >24 hours prior to your appointment would be most helpful. This will help speed things along when you arrive for your appointment!!!

Instead of filling the forms out by hand, one can also electronically complete (ie, type) and submit the new patient registration forms here.

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!

NOTE: These forms are to be completed by hand after printing. Optionally use the forms found here to electronically complete & submit.

Patient Registration Form (1 page)

New Patient Questionnaire (2 pages)

Privacy Notice Acknowledgement & Office Consent
(There are 2 places to sign on this form. The privacy notice can be read here.)

If you have no health insurance, complete this form

IF you are seeing us for allergies, complete this form

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)
  

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If you are a new patient, the following happens when you check-in (which is why a wait is sometimes inevitable):

  1. Creation of chart
  2. Copy made of insurance card
  3. Transferring the info on your forms into our electronic medical records
  4. Scanning of paperwork into our electronic database
  5. Creation of electronic prescribing record
  6. Pulling any MRI, CT, sleep study, etc reports from the hospital if you did not bring them with you and scanning them in.

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.