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Piedmont Family Practice Forms​

Below is a list of forms to fill out before your first visit or to request medical records.

Now Offering Tele-Health appointments per approval from your provider:

  • Tele-Health Information Sheet
  • Tele-Health Consent Form

New Patient Forms:

  • New Patient Welcome Form
  • PFP Patient Health History
  • PFP HIPPA Release
  • PFP Patient Information
  • PFP Financial Policy
  • Consent to Treat A Minor Form
  • New Patient Welcome Form
  • PFP Patient Health History
  • PFP HIPPA Release
  • PFP Patient Information
  • PFP Financial Policy
  • Consent to Treat A Minor Form

Request your Medical Records:

Phone: 540-900-2322.
Email: [email protected]
There is no fee to send records to a physician.
Fees for us to send personal records: $6.50 fee for chart w/ electronic delivery. $6.50 + shipping for chart w/ paper delivery. Requests will be completed within 10 days of receipt of the request.
If you would like to download/print the form to fill out, RRS Medical Record Request Form.
Request your Medical Records

See our other Patient Resources

Accepted Insurance
Learn about the accepted insurance policies.
Accepted Insurance Policies
First-Time Visit
Learn what to bring for your first-time visit.
First-Time Visit

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