Patient Registration Form

  • If you would like to sign up for FollowMyHealth please contact the office and ask for a patient portal invite or fill out the form below.
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Patient Registration Form

Parents/Guardian Information Form:

Parent/Guardian 2 Form:

Insurance Information Form:

Secondary Insurance Form:

Emergency Contact Form:

Siblings Form:

Pharmacy Information Form:

I hereby authorize RVA Pediatrics, P.C. to release information to the insurance company named herein. I hereby authorize payment directly to RVA Pediatrics, P.C. or benefits otherwise payable to me. I understand that I am financially responsible for charges not covered by this authorization. I agree that in the event that my account must be turned over to an attorney or agency for collection, that I will be responsible for agency or attorney’s fees as well as court cost and interest. Form:

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