Patient Information
Patient Demographics Form
An invitation to Kareo/Tebra Patient Portal will be sent to you once you have made an appointment. Once the patient portal has been activated, you will receive a request to complete all new patient paperwork.
Required Documents For Primary Care &/or Palliative Medicine Appointment
1) Copy of Photo ID - Valid Virginia State ID
2) Complete: (Forms will be sent via email)
- Demographics form
- Medical History Form
- Consent to Treat Form(s)
3) Submit payment prior to appointment (this can be sent via Paypal, Venmo, or invoiced by Square) or at time of services.
Please complete the forms electronically (sent via email/patient portal) prior to appointment. If you have any questions, please contact me at:
Email: rachael.the.np@gmail.com
Phone (voice/text): (540) 300-2026
Fax: 716-214-3792
Required Documents For Medical Cannabis Certification
1) Copy of Photo ID - Valid Virginia State ID
2) Complete:
- Demographic Form
- Medical History Form
3) Must provide one medical record with disclosure of one diagnosis from a primary care physician or specialist's with a chronic medical condition. ***This does not need to be a letter from an MD/NP/PA recommending medical cannabis! It just needs to be a document that lists a qualifying diagnosis!
Prior to appointment, please email or fax the above listed documents to:
Email: rachael.the.np@gmail.com
Fax: 716-214-3792
If any information is missing, your appointment will be re-scheduled until this information is received.