Patient Information

Required Field

Personal Info

First Name

Last Name

Pronouns

Date of Birth (MM/DD/YYYY)

Gender

Occupation

Contact Info

Mobile Phone

Home Phone

Source of Referral

Address

City

Country

Province / State

Postal / Zip Code

Emergency Contact

Emergency Phone

Relationship

Doctor

Doctor's Name

Doctor's Phone

Doctor's Address

Consent and Privacy Information

At Thrive Wellness RVA, we prioritize your health, safety, and privacy. The following section provides important details about general consent for treatment and HIPAA/privacy policies. Please take a moment to review the information and sign where required. If you have any questions, please do not hesitate to contact us for further clarification.

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Thrive Authorization and Consent (Review Required)

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Thrive 2025 NOTICE OF PRIVACY PRACTICES (NOTICE REGARDING PRIVACY OF PERSONAL HEALTH INFORMATION) (Review Required)

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Signature

Below is a list of persons who are authorized to view any medical information in this medical chart:

Name

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Relationship

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Phone Number

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Name

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Relationship

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Phone Number

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