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New River Family Wellness

Home
About Us
Future Patients
Direct Primary Care
Benefits
Pricing
FAQ
Testimonials
Flyers
Enrollment
Patients
Forms
Cosmetics
Patient Hub
Employer Hub
Apps
Testimonials
Education
Insurance
Community
Resources
Outreach
Non-Member Services
Employers
Learners
Español
Contact Us
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  • Cosmetics
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Patient Forms

Below you’ll find our most important legal policies for your review and reference. We’ll provide you with copies if needed in the office. Also, please note that these policies and forms are subject to change at any time, or with 30 day’s notice when required.


Patient Agreement with Appendices

Contract for Services Provided to Medicare Beneficiaries

Communication Consent

Notice of Privacy Practices

Combined Acknowledgment and Consent

Authorization to Obtain Health Information

Authorization to Release Health Information

Consent to Medical/Surgical Office Procedures

Botulinum Toxin and Dermal Filler History Form

Consent to Botulinum Toxin Procedure

Consent to Dermal Filler Procedure

Vaccination Consent Form

Patient Testimonial and Testimonial Release Form

Patient Photograph Release Form

Request for Confidential Communication of Personal Health Information

Request for Accounting of Disclosures of Personal Health Information

Request to Access, Inspect, and Copy Personal Health Information

Request for Amendment/Correction of Personal Health Information

Patient Privacy Complaint Report Form


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327 E Main St, Jefferson, NC(P) 1-336-489-4400 (F) 1-336-489-4500Info@NewRiverFamilyWellness.com
 
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