2002 Orange Road                          Located on Orange Road (Route 15)                         Phone: (540) 423 6239

Suite #201                                                                                                                              Fax: (540) 738 0105 

Culpeper, Virginia 22701                                                                                                  info@mypaincenter.org

Thank you for considering us to be part of your health care team. We are dedicated to providing you with outstanding health care and are committed to treating you with the utmost respect. Please take the time to learn more about our treatment philosophy by clicking here. Prior to your initial visit, be sure to read through the New Patient Registration Kit thoroughly and to ask us any questions you may have. To help expedite the initial process, please return the completed New Patient Registration Kit via fax (540-738-0105) or mail (2002 Orange Road, Suite #201 Culpeper, VA 22701). Also, be sure to print out and bring the completed New Patient Registration Kit form with you to your first appointment and to familiarize yourself with the Notice of Privacy Practices. This Notice of Privacy Practices explains how your protected health information may be used. Additional forms are located here for your convenience should they be required during the course of your care.

Use this form if you wish for another person such as a family member or an organization to have access to your health information.

Use this form if you wish for our office to send your medical records to another office