Forms2018-04-30T10:06:45+00:00

Patient Forms

When preparing for your appointment at Hampton Family Practice, please print and complete the applicable forms below and bring them with you to your appointment.

NEW PATIENT REGISTRATION FORMS

Patient Registration/Patient Update Form
Past Medical History Form

FUNCTIONAL MEDICINE INTAKE FORMS
Dr. Jennifer McCord
Jezeriah Cook, PA-C

PRIVACY NOTICE

We are committed to protecting the privacy of your protected health information.  Our Notice of Privacy Practices serves to explain how we may use and disclose your health information according to the Health Information Portability and Accountability Act (HIPAA).

MEDICAL RECORDS RELEASE

Virginia Code § 32.1-127.1:03 requires that most requests for copies of medical records must be made in writing.  Use the following forms to request copies of your medical records.

LIVING WILLS AND ADVANCE CARE PLANNING

If you are 18 or older, and mentally competent, then you have the right to make decisions about your medical care.  Advanced directives are legal forms that help you make decisions about you future medical care.

  • living will (PDF) lets you state your wishes about medical care, or choose another person to make decisions for you if you lose the ability to do so.

  • A healthcare power of attorney  lets you name the person to make health care decisions for you if you become unable to decide for yourself.

  • An advance instruction for mental health treatment allows you to give instructions and preferences about mental health treatment.  You may select somone to make these decisions for you if you lose the ability to decide for yourself.  This document automatically expires in two years.

ACCESS OUR PATIENT PORTAL

Our patient portal allows current patients to have secure access to various parts of their health information while providing another method of communication with our practice. It is not intended to replace a face-to-face office visit with our provider or for emergent needs. 

How to Sign Up

Visit our patient portal

ACCEPTING NEW PATIENTS

To request an appointment with Hampton Family Practice, please fill out our easy online form, and one of our scheduling coordinators will get in touch with within 48 hours.
Request An Appointment