Family Healthcare of Fairfax, PC Patient Portal

Family Healthcare of Fairfax, P.C.

This information will be placed in your confidential medical record and will be used exclusively by the medical practice of Family Healthcare of Fairfax, PC to facilitate care.

Patient Information

Please fill out all of the fields below.

First, Middle, and Last Name * Full Home Address * City, State Zip Code * Email * Date of Birth * Name of Spouse/Partner? (Full Name) Sex * Marital Status * Work and Cell Phone Numbers * Pharmacy Name and Phone Number * Please indicate your preferred contact phone #: * May we leave a detailed message at your preferred phone #? * May we release your medical information to your spouse/partner? * Do you check your email on a regular basis? * May we send health information by email? * Do you have dependent children signed up for the practice? * If yes, please list names:

Emergency Contact Information

Please indicate an alternate contact:

Last Name, First Name and Relationship To You * Home Phone # and Other Phone # *

Insurance Information

PRIMARY INSURANCE CO. AND FULL ADDRESS * Policy # AND Group # * Policy Holder's Name, DOB, Sex, and SSN: * Employer, Work Phone, and Full Work Address: * Relationship of Patient to Policy Holder: * SECONDARY INSURANCE CO. AND FULL ADDRESS Policy # AND Group # Policy Holder's Name, DOB, Sex, and SSN: Employer, Work Phone, and Full Work Address: Relationship of Patient to Policy Holder: Patient Signature * Date *