Patient Resources

Forms & Information

School Forms

Entrance Physical

Sports Physical Form

Medication Administration Form

Vaccine Information Sheets

Important information from the Center for Disease Control on the childhood immunizations we give in our office:

DTaPHepatitis BHaemophilus Influenza Type BMMRPneumococcal (child),

Varicella (chicken pox)TDaP (boostrix)Gardisil (HPV)Menactra (Meningiococcal)

Links to General Medical Information

Virginia Department of Health

CDC Website

General Assistance:


Meals on Wheels

Peninsula Agency on Aging

Quit Smoking!!

External Content Disclaimer

*Please note that pages of this site may be linked to other websites, which may have different terms of use and privacy practices than Privia Medical Group. Privia does not own, control, manage, supervise, direct, or otherwise have involvement in such other websites or the content of such websites. Privia is not responsible for the content of any linked websites. Privia is not acting as an agent for these websites, nor does Privia endorse or guarantee, in any way, their websites, content, or products. Privia makes no representation or warranty regarding the accuracy of information contained in linked websites, takes no responsibility for the use of copyrighted or otherwise protected materials on such linked websites, and has no control over the privacy practices or use of user information at such linked websites.

Patient Forms

Authorization for Release of Medical Information (PDF) – Allows patients to authorize the disclosure of their health information to a designated individual, company, agency, or facility.

Authorization and Consent for Treatment (PDF) – All patients must provide their consent for treatment, communications (calls, emails, and text messaging), and agreement of financial responsibility.

Preventive Medical Visit Patient Information (PDF) – Details financial responsibilities regarding preventive medical visits.


Office Policies

Financial Policy (PDF) – This form advises patients of their complete financial responsibility for all medical services received without regard to insurance eligibility or coverage determinations.
Notice of Privacy Practices (PDF) – Describes how health information about you (as a patient of this Care Center) may be used and disclosed, and how you can get access to your individually identifiable health information. Please review this notice carefully.