New Patient Registration, Information, and Other Forms

Optionally, you can also download the electronic pdf version you can type in rather than the plan pdf which you have to handwrite. Make sure to complete and print the entire patient registration form (4 pages)! Also bring with you to your appointment the following to help speed things along. PLEASE give these reports immediately to the check-in person so we can get them scanned into our medical records (prevents check-out delays)

• MRI Scan Reports (if NOT done at Fauquier Hospital)
• CT Scan Reports and CD disc (if NOT done at Fauquier Hospital)
• Barium Swallow Reports (if NOT done at Fauquier Hospital)
• Sleep Study and CPAP Reports
• Upper Scope by GI Doctor Reports
• Allergy Test Results
• List of all your medications
• BRING your actual health insurance card and a photo ID (Driver's License)
• Referral authorization sent to our office PRIOR to your appointment (if applicable)

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!!!

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 BEFORE your appointment!

Here are some other forms that may also apply depending on your symptoms and situation:

• If you have no health insurance or insurance our office does not participate with, 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
• 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.
• The privacy notice can be read here.

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.