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Fax Number: 804-378-5400
ATTENTION: Due to exceptionally high call volume, our response time to phone messages may be delayed. To ensure we can assist you as quickly as possible, we encourage you to use our Patient Portal for non-urgent communication.
Self-Referral
Patients
Taking the first step toward relief is an important decision, and you don't have to make it alone. If you are considering treatment options independently, we welcome the opportunity to help you determine whether our treatments are the right choice for you.
The Self-Referral Process
To begin the process of becoming a new patient, you’ll need to complete and submit a self-referral form. The following steps will guide you through printing, filling out, and submitting your form for review. Please note that submitting a form does not guarantee you will be seen; all forms are carefully reviewed by our team. This review typically takes 24 to 72 hours. If you meet our eligibility criteria, we will contact you to arrange your first appointment.
Please Follow the Steps Below:
Step 1: Fill Out The Form
Option 1: Print and Drop Off Form
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Download and print the self-referral form​​​​
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Fill out the forms at your convenience.​
Step 3: Review by Provider
Once we receive your form, our team will review the information provided.
Normally, the process takes about 24 to 72 hours, and once you qualify, our team will reach out to you to schedule an appointment.
Option 2: Complete Forms In-Office
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Fill out the paperwork at any of our office locations.
Step 2: Submit Forms for Review
Once you have completed your form, please drop it off at one of our three convenient office locations - Sommerville, Johnstone Willis or Mechanicsville.
Step 4: Contact Us with Questions
If you have any questions or need assistance with your paperwork, please contact our office via text at 804-223-0456 or give us a call at 804-378-1800 option 1. We are here to help!
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