Registration Form for New Patients

Registration Form
Welcome to Richmond Spine Interventions and Pain Center! We would like you to know that we appreciate the chance to care for you. Our office is committed to providing you with the highest quality of care possible. We will make every effort to ensure that your visit with us is a comfortable experience. To help you better with your upcoming visit, we need some important information. Please complete all 5 sections of this form.

Patient Demographic Form
Patient Demographic Form
Full Name *

First Name Middle Name Last Name
Date of Birth *

Month Day Year
Address *

Street Address

Street Address Line 2

City State

Zip Code
Home Phone *

Area Code Phone Number
Mobile Number

Area Code Phone Number
Contact Preference *

Home Phone Mobile
Can we send you a mobile text message? (This is for appointment reminders or patient portal registration. We promise not to spam you!) *

Yes No
Email
Providing your email address authorizes RSIP to send electronic correspondence to you. You may unsubscribe at any time.
Language *
Race
Ethnicity

Hispanic Non-Hispanic
Marital Status *
Emergency Contact *

First Name Last Name
Relationship to Patient *
Example: Spouse, Sibling, Parent, Friend, etc
Emergency Contact Phone *

Area Code Phone Number
Who is your Primary Care Physician? *

First Name Last Name
What is their office phone number?

Area Code Phone Number
Which physician referred you to our office?
What is their office phone number?

Area Code Phone Number
What is your preferred pharmacy? *
Pharmacy Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Pharmacy Phone Number

Area Code Phone Number
Primary Insurance Company *
Type none for no insurance
Subscriber Number
type none for no insurance
Subscriber number currently not available:

Would like to discuss this with my provider later
Secondary Insurance Company
Subscriber Number
Any Additional Insurance Company
Would you like to register for the patient portal?

Yes, please! Not today, thanks!

Cancellation / No Show Policy
Cancellation / No Show Policy
Our goal is to provide quality individualized medical care in a timely manner. No-shows, late shows and cancellations inconvenience those individuals who need access to medical care. We would like to remind you of our policy regarding missed appointments.

If it is necessary to cancel your scheduled appointment, we require that you call at least 24 hours in advance. Appointments are in high demand, and your early cancellation will allow another patient access to timely medical care.

By making an initial appointment with one of our physicians, nurse practitioner, or physician assistant, you are agreeing to abide by the billing policies of our practice. There will be a fee, billed to you personally, if you do not provide at least a 24-hour notice of cancellation or change to your appointment date/time.

How to Cancel Your Appointment
To cancel your appointment, please call 804-378-1800. If you do not reach the call center, you may leave a detailed message on our voicemail. If you would like to reschedule your appointment, please leave your name and phone number. We will return your call promptly.

Late Cancellations: A cancellation is considered to be late when the appointment is canceled without 24-hour advance notice.

No Show Policy: A “no-show”, is a patient who misses an appointment without canceling it. A failure to be present at the time of a scheduled appointment will be recorded in the patient’s chart as a “no-show”.

There are no health insurance policies that cover fees for missed appointments or 'no shows'.

Our staff will be happy to answer any further questions regarding this policy.
Signature
Signature *

Clear
Name *

First Name Last Name
Relationship to Patient
Only if signed by someone other than the patient
Today's Date *

Month Day Year

Authorization to Discuss or Release Confidential Patient Information
Authorization to Discuss or Release Confidential Patient Information
Contact 1

First Name Last Name
Relationship to Patient
Contact 2

First Name Last Name
Relationship to Patient
Decline

I do not give permission to anyone other than myself to receive my medical or financial information, this includes picking up prescriptions or other documents related to my care. Would like to discuss with provider
If Richmond Spine Interventions and Pain Center is unable to reach you in person for any reason (lab results, referrals, appointments, prescriptions, etc) Do we have permission to leave a message on your voicemail? *

Yes No
Please Confirm Your Phone Number

Area Code Phone Number
Signature
Signature *

Clear
Name of Patient or Guardian Signing Above *

First Name Last Name
Date *

Month Day Year

Release of Medical Information for Billing Purposes
Release of Medical Information for Billing Purposes
Signature
Signature *

Clear
Date *

Month Day Year

Payment for Medical Services
Payment for Medical Services
Signature
Signature *

Clear
Date *

Month Day Year

Submit Form
NOTE: Upon submitting the form, please wait until you reach the "Thank You" page before exiting.

If you have trouble submitting this form, DO NOT exit out of this form and call our office at 804-378-1800 for assistance. (if you're calling after office hours, please leave a message and we will get back to you as soon as possible)
Should be Empty:

Registration Form

Patient Demographic Form

Cancellation / No Show Policy

Authorization to Discuss or Release Confidential Patient Information

Release of Medical Information for Billing Purposes

Payment for Medical Services