Forms

New patient forms

Please make sure you click on each form to view/print and fill out #1 – 11 completely before returning the forms to Bassett Family Practice or Ridgeway Family Health.

icon of pencil and clipboard

  1. New Patient Welcome Letter
  2. Prescribing Notice
  3. MedAssist Information
  4. Patient Demographics (2018)
  5. Reduced Fee Eligibility Application
  6. History Questionnaire
  7. Authorization for Release of Information
  8. Cancellation Notice
  9. Consent to Treat
  10. Patient Portal Guidelines
  11. Notice of Privacy Practices/HIPAA

 

e-BACKPAC (Electronic Better Health And Care for Kids, Parents and Communities) – a collaboration of community partners to provide access to doctors, nurses, behavioral health counselors, etc. through telehealth so that students and teachers do not have to leave school for an appointment. Fill out/print and return completed registration form to your child’s participating* school.

e-BACKPAC Registration Form

participating* – currently this program operates in Martinsville City Public Schools and Patrick County Public Schools.