Patient Forms

Save time and help us make your first visit run efficiently. Please complete the online health questionnaire at your convenience PRIOR to the consultation.

Secure Online New Patient Registration Form

Note: Make sure to fill all required fields and click submit.

 

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March 25, 2016

We are pleased to inform you that we will be processing payments via VANCO Payment Solutions, which is a PCI Level 1 Compliant Service Provider.  VANCO maintains an Information Security Policy and a Computer Security Incident Response Plan. All confidential data transmitted by VANCO over any public communication network is encrypted by strong cryptography and encryption techniques. In other words, your personal information will be more secure and closely monitored for any fraudulent activity.

The next step requires us to update your method of payment, as your card information was never (and will not be) directly stored on site for security reasons.  The update will include the aforementioned encryption process.  Additionally, you now can set up automatic monthly payments using your checking account (ACH debits).  Please complete and submit the authorization agreement, along with a voided check before May 6, 2016. This will help assure your payment is processed without any interruptions.

If you have any questions or concerns please call Donna or Tom at 804-737-8777.  Thank you in advance for your cooperation.

 

Direct payments authorization agreement PDF