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.
- New Patient Welcome Letter
- Prescribing Notice
- MedAssist Information
- Patient Demographics (2018)
- Reduced Fee Application
- History Questionnaire
- Authorization for Release of Information
- Cancellation Notice
- Consent to Treat
- Patient Portal Guidelines
- 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.
participating* – currently this program operates in Martinsville City Public Schools and Patrick County Public Schools.