|
Patient Information
The following forms are available for your convenience. To expedite your first check in procedure please fill these forms out and bring them with you on your first appointment.
|
Note:
To open the files below you may do the following: Click the link to
open up the document in a
browser window (if you get a user login and password screen, please
ignore it by hitting cancel. The
document will still open); or you may also download the file by right-clicking
the link, then saving the
target
source to your hard drive. Just note the where you saved the file
for future reference. |
|
Consent For Use and Disclosure of
Health Information
By signing these forms, you will consent to our use and disclosure of your protected
health
information {PHI] to carry out treatment, payment activities and healthcare operations.
|
All of the following
documents are in Microsoft Word Format (.doc). Click the
individual files to open them in your internet browser.
|
If you wish to download all
of these documents for later use. Please, click on the link
below to download the zipped version of all files.
|
|
|
Acknowledgement of Receipt for
Notice of Privacy Practices
To obtain acknowledgement of receipt of our notice of privacy practices.
|
The following document is in
Microsoft Word Format (.doc). Click the individual file to
open it in your internet browser.
|
If you wish to download this
document for later use. Please, click on the link below to
download the zipped version of this file.
|
|
|
Child Patient Care Forms
These forms are to be filled out in its entirety for children ages 3-17.
|
All of the following
documents are in Microsoft Word Format (.doc). Click the
individual files to open them in your internet browser.
|
If you wish to download all
of these documents for later use. Please, click on the link
below to download the zipped version of all files.
|
|
|
Adult Patient Care Forms
These forms are to be filled out in its entirety for adults ages 18 and up.
|
All of the following
documents are in Microsoft Word Format (.doc). Click the
individual files to open them in your internet browser.
|
If you wish to download all
of these documents for later use. Please, click on the link
below to download the zipped version of all files.
|
|
Lefcoe, Weinstein, Sachs, Schiff & Associates
300 E Little Creek Road
Norfolk
Virginia
23505
(757) 587-6453 |
904 Kempsville Road
Virginia Beach
Virginia 23464
(757) 467-6453 |
1230 Progressive Drive
Chesapeake
Virginia 23320
(757) 436-1270 |
1157 First Colonial Road
Virginia Beach
Virginia 23454
(757) 412-1114 |
|
