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Patient Office Guide

Patient Appointment Forms

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Registration Form

If you've been contacted about a recall procedure or appointment, please go to the "RECALL PROCEDURE PAPERWORK" tab on the left and complete your forms there.

For your protection, Registration and Medical History Forms are sent via a secure transmission directly to FCRS’s server. They are not sent via email

* – Required field

Patient Information
Patient’s Name
Marital status:
Birth Date:*
Sex:
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Insurance Information
Subscriber’s Birth Date:
Patient’s relationship to subscriber:
Is the subscriber also responsible for payment?
Birth Date:
()
Is the patient employed?
()
Patient’s relationship to subscriber:
In Case of Emergency
()
()

The above information is true to the best of my knowledge. I have read a copy of the following office policies and procedures (Rev 5/26/2010): Privacy (HIPAA) , Office Visit Policies and Surgical Center Policies (including Financial Responsibilities), Patient Bill of Rights and Responsibilities (including advanced directives), Electronic Communication Policy. By my signature below, I agree to adhere to all such policies. I have also read and agree to the Electronic Communications policy, which permits the use of email for non-medical communication. I may make changes to my email election and/or individuals authorized to discuss my medical information at any time. In addition, copies of these policies and procedures have been offered to me, and are available on the website, www.fairfaxcolorectal.com. If I do not elect to take them today, I may request a written copy at any time.