{"id":1102,"date":"2020-06-25T02:28:31","date_gmt":"2020-06-25T02:28:31","guid":{"rendered":"https:\/\/www.vdh.virginia.gov\/rappahannock\/?page_id=1102"},"modified":"2025-08-08T13:41:04","modified_gmt":"2025-08-08T17:41:04","slug":"forms","status":"publish","type":"page","link":"https:\/\/www.vdh.virginia.gov\/rappahannock\/services\/forms\/","title":{"rendered":"Forms"},"content":{"rendered":"<p>Rappahannock Area Health District Client Registration Form: <a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/114\/2020\/06\/clinicformsforthewebsite.zip\" rel=\"attachment wp-att-1103\">English<\/a>, <a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/114\/2020\/06\/Client-Registration-Spanish.doc\" rel=\"attachment wp-att-1104\">Spanish<\/a><\/p>\n<p>Informed Consent for Special Health Services and Procedures: <a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/114\/2020\/06\/English_CHS-1B_consent_for_spec_services-1.docx\" rel=\"attachment wp-att-1105\">English<\/a>, <a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/114\/2020\/06\/Spanish_CHS-1B_consent_for_spec_services-1.docx\" rel=\"attachment wp-att-1106\">Spanish<\/a><\/p>\n<p>Patient Bill of Rights: <a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/114\/2020\/06\/EnglishPatientsBillofRights2007b_000-1.doc\" rel=\"attachment wp-att-1107\">English<\/a>, <a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/114\/2020\/06\/SpanishPatientsBillofRights2007b-1.doc\" rel=\"attachment wp-att-1108\">Spanish<\/a><\/p>\n<p>General Health History: <a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/114\/2020\/06\/GENERAL-HEALTH-HISTORY-2-28-20-ENGLISH.pdf\" rel=\"attachment wp-att-1109\">English<\/a>, <a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/114\/2020\/06\/GENERAL-HEALTH-HISTORY-2-28-20_Spanish.pdf\" rel=\"attachment wp-att-1110\">Spanish<\/a><\/p>\n<p>HIPAA Authorization: <a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/114\/2020\/06\/HIPAAAuthorizationforDisclosureofPHI.doc\" rel=\"attachment wp-att-1111\">English<\/a>, <a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/114\/2020\/06\/HIPAAAuthorization_SP.doc\" rel=\"attachment wp-att-1112\">Spanish<\/a><\/p>\n<p>Immunization Consent: <a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/114\/2025\/05\/CHS2_Sep_2024.doc\">English<\/a>, <a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/114\/2025\/05\/CHS2_SP_Sep_2024.doc\">Spanish<\/a><\/p>\n<p><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/114\/2025\/05\/Fillable-TB-Risk-Assessment-512-and-Instructions_Nov-2021.pdf\">TB Risk Assessment<\/a>(Please only complete the top portion of this form)<\/p>\n<p>Authorization to Use and Exchange Information: <a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/114\/2020\/06\/UAIConsent-1.pdf\" rel=\"attachment wp-att-1116\">English<\/a>, <a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/114\/2020\/06\/UAIConsent_SP-1.docx\" rel=\"attachment wp-att-1117\">Spanish<\/a><\/p>\n<p>Visit Health History: <a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/114\/2025\/08\/SEXUAL_HEALTH_HISTORY_2024-12-30.pdf\" target=\"_blank\" rel=\"noopener\">English<\/a>, <a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/114\/2025\/08\/202412_SEXUAL_HEALTH_HISTORY_Spanish_revised.pdf\" target=\"_blank\" rel=\"noopener\">Spanish<\/a><\/p>\n<p><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/114\/2020\/06\/Voter-Registration-AgencyCertificationForm-0709_000-2.pdf\" rel=\"attachment wp-att-1120\">Voter Registration Form<\/a><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Rappahannock Area Health District Client Registration Form: English, Spanish Informed Consent for Special Health Services and Procedures: English, Spanish Patient Bill of Rights: English, Spanish General Health History: English, Spanish HIPAA Authorization: English, Spanish Immunization Consent: English, Spanish TB Risk Assessment(Please only complete the top portion of this form) Authorization to Use and Exchange Information: [&hellip;]<\/p>\n","protected":false},"author":689,"featured_media":0,"parent":11,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_lmt_disableupdate":"no","_lmt_disable":"","footnotes":""},"tags":[],"class_list":["post-1102","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.3 - 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