PATIENT FEEDBACK FORM
Please complete the form below to tell us about your experience.
Please include the patient’s name and tell us how you are related to the patient. We also need the
NAMEs of the staff who have taken care of you.
Thank you for trusting us with your medical care. We look forward to serving you again.
You may send us and email at : admin@centercareva.com if you prefer that route.[/vc_column_text][gravityform id=”1″ title=”false” description=”false” ajax=”false”][/vc_column][vc_column column_padding=”no-extra-padding” column_padding_tablet=”inherit” column_padding_phone=”inherit” column_padding_position=”all” column_element_spacing=”default” background_color_opacity=”1″ background_hover_color_opacity=”1″ column_shadow=”none” column_border_radius=”none” column_link_target=”_self” gradient_direction=”left_to_right” overlay_strength=”0.3″ width=”1/2″ tablet_width_inherit=”default” tablet_text_alignment=”default” phone_text_alignment=”default” bg_image_animation=”none” border_type=”simple” column_border_width=”none” column_border_style=”solid”][image_with_animation image_url=”11″ animation=”Grow In” hover_animation=”none” alignment=”” border_radius=”none” box_shadow=”none” image_loading=”default” max_width=”100%” max_width_mobile=”default” el_class=”book-imggg”][/vc_column][/vc_row][vc_row type=”full_width_content” full_screen_row_position=”middle” column_margin=”default” column_direction=”default” column_direction_tablet=”default” column_direction_phone=”default” scene_position=”center” top_padding=”80″ bottom_padding=”80″ left_padding_desktop=”30″ text_color=”dark” text_align=”left” row_border_radius=”none” row_border_radius_applies=”bg” id=”form-roww” overlay_strength=”0.3″ gradient_direction=”left_to_right” shape_divider_position=”bottom” bg_image_animation=”none” shape_type=””][vc_column column_padding=”no-extra-padding” column_padding_tablet=”inherit” column_padding_phone=”inherit” column_padding_position=”all” column_element_spacing=”default” background_color_opacity=”1″ background_hover_color_opacity=”1″ column_shadow=”none” column_border_radius=”none” column_link_target=”_self” gradient_direction=”left_to_right” overlay_strength=”0.3″ width=”1/3″ tablet_width_inherit=”default” tablet_text_alignment=”default” phone_text_alignment=”default” bg_image_animation=”none” border_type=”simple” column_border_width=”none” column_border_style=”solid”][vc_column_text css_animation=”fadeInRight”]
ADULTS FORMS
NEW Patient Forms-ADULTS:
Establishing Primary Care Form- Adults
Medication List:
Problem List and Health Maintenance:
NEW PATIENT- DEMOGRAPHIC Form (ADULT)
HISTORY FORM-New Patient (ADULT)
Insurance Form
Consent for Treatment
Establishing Care Form (ADULT)[/vc_column_text][/vc_column][vc_column column_padding=”no-extra-padding” column_padding_tablet=”inherit” column_padding_phone=”inherit” column_padding_position=”all” column_element_spacing=”default” background_color_opacity=”1″ background_hover_color_opacity=”1″ column_shadow=”none” column_border_radius=”none” column_link_target=”_self” gradient_direction=”left_to_right” overlay_strength=”0.3″ width=”1/3″ tablet_width_inherit=”default” tablet_text_alignment=”default” phone_text_alignment=”default” bg_image_animation=”none” border_type=”simple” column_border_width=”none” column_border_style=”solid”][vc_column_text css_animation=”fadeInRight”]
PEDIATRIC FORMS:
NEW Patients form- PEDIATRICS:
Establishing Primary Care Form- PEDIATRICS
Pediatric History Record:
School Physical form-VIRGINIA:
Sport Physical Form:
HPV Vaccines:
Establishing Care-Problem List And Heath Maintenance
NEW PATIENT- DEMOGRAPHIC Form (PEDIATRIC)
HISTORY FORM – New Patient (PEDIATRIC)
Insurance Form
Consent for Treatment[/vc_column_text][/vc_column][vc_column column_padding=”no-extra-padding” column_padding_tablet=”inherit” column_padding_phone=”inherit” column_padding_position=”all” column_element_spacing=”default” background_color_opacity=”1″ background_hover_color_opacity=”1″ column_shadow=”none” column_border_radius=”none” column_link_target=”_self” gradient_direction=”left_to_right” overlay_strength=”0.3″ width=”1/3″ tablet_width_inherit=”default” tablet_text_alignment=”default” phone_text_alignment=”default” bg_image_animation=”none” border_type=”simple” column_border_width=”none” column_border_style=”solid”][vc_column_text css_animation=”fadeInRight”]
General Forms
Office Policies
Patient Rights and Responsibilities
BLOOD GLUCOSE LOG
Medical Records Release form – patient 18yo and older
Medical Records Release Form- Pediatric Patient
Notice of Privacy Practice
TEXT MESSAGE AGREEMENT
[/vc_column_text][/vc_column][/vc_row][vc_row type=”full_width_content” full_screen_row_position=”middle” column_margin=”20px” column_direction=”default” column_direction_tablet=”default” column_direction_phone=”default” scene_position=”center” top_padding=”80″ bottom_padding=”80″ left_padding_desktop=”30″ text_color=”dark” text_align=”left” row_border_radius=”none” row_border_radius_applies=”bg” id=”form-roww” overlay_strength=”0.3″ gradient_direction=”left_to_right” shape_divider_position=”bottom” bg_image_animation=”none” shape_type=””][vc_column column_padding=”no-extra-padding” column_padding_tablet=”inherit” column_padding_phone=”inherit” column_padding_position=”all” column_element_spacing=”default” background_color_opacity=”1″ background_hover_color_opacity=”1″ column_shadow=”none” column_border_radius=”none” column_link_target=”_self” gradient_direction=”left_to_right” overlay_strength=”0.3″ width=”1/2″ tablet_width_inherit=”default” tablet_text_alignment=”default” phone_text_alignment=”default” bg_image_animation=”none” border_type=”simple” column_border_width=”none” column_border_style=”solid”][vc_column_text css_animation=”fadeInRight”]
MEDICAL RECORDS Request
Please complete the form and fax it as instructed below
Fax the form to:
- 888-801-8599, if you live in King George
- 540-699-0214, if you live in Fredericksburg
- 540-322-2706, if you live in Locust Grove
Medical Records Release Form:
https://acrobat.adobe.com/id/urn:aaid:sc:
US:2e2036ce-e7f7-41a1-95b2-08eac9554150[/vc_column_text][/vc_column][vc_column column_padding=”no-extra-padding” column_padding_tablet=”inherit” column_padding_phone=”inherit” column_padding_position=”all” column_element_spacing=”default” background_color_opacity=”1″ background_hover_color_opacity=”1″ column_shadow=”none” column_border_radius=”none” column_link_target=”_self” gradient_direction=”left_to_right” overlay_strength=”0.3″ width=”1/2″ tablet_width_inherit=”default” tablet_text_alignment=”default” phone_text_alignment=”default” bg_image_animation=”none” border_type=”simple” column_border_width=”none” column_border_style=”solid”][vc_column_text css_animation=”fadeInRight”]
HELPFUL LINKS:
Health Insurance: Do you need Health Insurance?
MEDICARE PREVENTIVE CARE SERVICES
https://www.medicare.gov/publications/
10110-Your-Guide-to-Medicare-Preventive-Services.pdf
Medicaid Information-Virginia:
https://www.dmas.virginia.gov/
Medicaid Information
Medicaid Formulary
https://www.dmas.virginia.gov/for-members/
prescription-drug-formularies/
Medicaid- How to Change your Health Plan
https://www.dmas.virginia.gov/for-members/
managed-care-programs/change-your-health-plan/
MEDICARE
Older Adults and Healthy Aging
https://www.cdc.gov/aging/olderadultsandhealthyaging/
index.html
PREVENTIVE CARE RECOMMENDATIONS FOR CHILDREN AND ADULTS:
Preventive Health Guidelines:
https://www.anthem.com/docs/public/inline/
17112VAMENBVA.pdf[/vc_column_text][/vc_column][/vc_row][vc_row type=”in_container” full_screen_row_position=”middle” column_margin=”default” column_direction=”default” column_direction_tablet=”default” column_direction_phone=”default” scene_position=”center” text_color=”dark” text_align=”left” row_border_radius=”none” row_border_radius_applies=”bg” overlay_strength=”0.3″ gradient_direction=”left_to_right” shape_divider_position=”bottom” bg_image_animation=”none” shape_type=””][vc_column column_padding=”no-extra-padding” column_padding_tablet=”inherit” column_padding_phone=”inherit” column_padding_position=”left” column_element_spacing=”default” background_color_opacity=”1″ background_hover_color_opacity=”1″ column_shadow=”medium_depth” column_border_radius=”none” column_link_target=”_self” gradient_direction=”left_to_right” overlay_strength=”0.3″ width=”1/3″ tablet_width_inherit=”default” tablet_text_alignment=”default” phone_text_alignment=”default” bg_image_animation=”none” border_type=”simple” column_border_width=”none” column_border_style=”solid”][nectar_btn size=”medium” open_new_tab=”true” button_style=”regular” button_color_2=”Accent-Color” icon_family=”none” text=”Text Message Agreement” url=”https://acrobat.adobe.com/id/urn:aaid:sc:US:857a7bb9-5f9b-4c4f-a71c-b64da8de574a?viewer%21megaVerb=group-discover”][/vc_column][vc_column column_padding=”no-extra-padding” column_padding_tablet=”inherit” column_padding_phone=”inherit” column_padding_position=”all” column_element_spacing=”default” background_color_opacity=”1″ background_hover_color_opacity=”1″ column_shadow=”none” column_border_radius=”none” column_link_target=”_self” gradient_direction=”left_to_right” overlay_strength=”0.3″ width=”1/3″ tablet_width_inherit=”default” tablet_text_alignment=”default” phone_text_alignment=”default” bg_image_animation=”none” border_type=”simple” column_border_width=”none” column_border_style=”solid”][/vc_column][vc_column column_padding=”no-extra-padding” column_padding_tablet=”inherit” column_padding_phone=”inherit” column_padding_position=”all” column_element_spacing=”default” background_color_opacity=”1″ background_hover_color_opacity=”1″ column_shadow=”none” column_border_radius=”none” column_link_target=”_self” gradient_direction=”left_to_right” overlay_strength=”0.3″ width=”1/3″ tablet_width_inherit=”default” tablet_text_alignment=”default” phone_text_alignment=”default” bg_image_animation=”none” border_type=”simple” column_border_width=”none” column_border_style=”solid”][/vc_column][/vc_row]
