New Patient Paperwork

Starting January 2022 we will be accepting New Patients!

 

Before an appointment can be made we will need the paperwork filled out and sent to the office. You can drop off anytime during our business hours or mail us the forms.

 

 

Mailing address is:

Riverdale Family Medicine, PA

PO BOX 760

Smithfield, NC 27577

 

Welcome to your Medical Home!
1.pdf
Adobe Acrobat document [37.8 KB]
Requirements for patient
2.pdf
Adobe Acrobat document [27.4 KB]
Patient Information Sheet
3.pdf
Adobe Acrobat document [54.5 KB]
Patient Health History
4.docx
Microsoft Word document [16.6 KB]
Review of Symptoms
5.xlsx
Microsoft Excel sheet [15.2 KB]
HIPPA Privacy Authorization Form
6.docx
Microsoft Word document [12.9 KB]
Notice of Payment & Credit
7.pdf
Adobe Acrobat document [44.0 KB]
Consent for the use of PHI
8.pdf
Adobe Acrobat document [42.2 KB]

 

Consentimiento para el uso de PHI

 

Estaremos aceptando Neuvo Pacientes en Enero 2022!

 

Antes de hacer una cita, nece que usted complete las formas y las regrese a la oficina durante nuestras horas de oficina, o las mande por correo.

 

 

Direccion postal

Riverdale Family Medicine, PA

PO BOX 760

Smithfield, NC 27577

 

Download
¡Bienvenido a su hogar médico!
New file download
Requisitos de los pacientes
2.doc
Microsoft Word document [24.5 KB]
Hoja de información para el paciente
3.doc
Microsoft Word document [41.0 KB]
Historial de salud del paciente
4.docx
Microsoft Word document [17.7 KB]
Revisión de síntomas
5.doc
Microsoft Word document [38.0 KB]
Formulario de autorización de privacidad de HIPPA
6.docx
Microsoft Word document [15.7 KB]
Aviso de pago y crédito
7.doc
Microsoft Word document [24.5 KB]
Download
Consentimiento para el uso de PHI
New file download