Patient Forms

New Patient Paperwork

In an effort to make your visit with us as smooth and efficient as possible; we have provided below the necessary registration paperwork needed at your first visit.  Please complete the forms and bring them with you to your appointment.  If you provide the office with an email address, you will be able to complete this process through our patient portal.

• New Patient Welcome & Instructions (you do not have to print this document)

• New Patient Registration Form

• Financial Policy Form

• Release of Information Form & Privacy Practice Notice

Patient Survey

We value the trust you have placed in us to provide for your healthcare needs. We would like to know how you feel about the services we provide so we can make sure we are meeting your needs. Your responses are directly responsible for improving these services. All responses will be kept confidential and anonymous.          

• Patient Satisfaction Survey

Medical Records Release

If you are in need of a copy of your medical record or a portion of your medical record, we require a completed medical records release form.  You can also complete this release form if you have medical records from another provider/location that you would like to make a part of your CMH ENT record.

• Medical Record Release Form

Pay Agreements

We understand that there may be times of financial difficulty in life, which is why we offer payment agreements when needed.  If you are in need of a payment agreement, please call us or come by the office to discuss your options.

For self-pay patients (no insurance), we require a $100.00 payment towards your account at your initial visit.  We also require that you establish a pay agreement with us at this time.

If you are an employee of  VCU Community Memorial Hospital (CMH) we also offer payroll deductions. 

Please contact the office at 434-447-3070 to establish payment arrangements.