we value your time
With today's fast-paced lifestyles, healthcare consumers in Hampton Roads need their care to be streamlined and hassle-free. For your convenience, we provide patient forms that are standard for all Bon Secours Primary Care locations. Print and complete the forms and bring to your first appointment. You’ll save minutes and eliminate the guesswork and juggling that comes from completing clipboard forms at the office.
If you have an HMO insurance plan, please call your insurance company to change the doctor listed on your plan to the Bon Secours physician you will be seeing.
- Annual Patient Information Validation Form (.pdf)
This form is required of every new patient. Complete it and bring to your first appointment. This form asks for address and contact, and health insurer/HMO information.
- Patient History Form (.pdf)
This form asks you questions about your medical history, including your past illnesses, major surgeries, and current prescriptions. Make sure that you are including all pertinent medical information so your physician can be as informed as possible.
- Permission to Disclose Private Health Information (PHI) (.pdf)
The release of protected health information is a standard form used by medical practices to safeguard the sharing of your personal health information. To complete it, you will need to know what information you wish to share and the contact information of the person or office it will be shared with.
- Authorization for Treatment (.pdf)
This form gives authority for your medical treatment to the physician, the clinical staff and technical employees assigned to your care. It also includes a privacy and disclosure section.
We look forward to providing you with excellent care. If you have any questions or need help finding a doctor, please call us at 889-CARE (2273).