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  • New Patient Registration Form
  • 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

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    • 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.

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    • Authorization to Discuss or Release Confidential Patient Information  
    • Authorization to Discuss or Release Confidential Patient Information

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    • Release of Medical Information for Billing Purposes  
    • Release of Medical Information for Billing Purposes

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    • Payment for Medical Services  
    • Payment for Medical Services

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    • 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)

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