Patient Registration Forms & Privacy Notices
If you are a new patient, please fill out the registration forms listed below in advance of your appointment to assist the staff in making sure that we have all the information necessary to provide you with quality care and treatment. Please bring the completed forms with you to your appointment.
- Notice to All Patients
- New Patient Forms - Dr. Cutter
- Prescription Medication List
- First Point of Contact Screening
- Consent for Treatment and Payment Agreement
- Patient Financial Agreement
- Patient HIPAA Acknowledgment and Consent (PRINT)
Athlete Participation and Release Forms
- Athlete Participation/Parental Consent for Physical Exam Form (Virginia High School League)
- Saturday Morning Injury Clinic (SMIC)
- Concussion Medical Release
- Physician Release Form for Wrestler to Participate with Skin Lesions
- Cast Rule Physician's Release (Soccer)
- Cast Rule Physician's Release (Football)
Patient Rights & Responsibilities
We respect our patients’ dignity and pride. This document will explain your patient rights and responsibilities. It is part of your patient registration and is an important part of your health care plan.
This privacy notice describes how health information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
- Notice of Privacy Practices (provided for you at your first visit)
- Aviso Sobre Las Practicas De Privacidad (proporcionada por usted en su primera visita)
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