Patient Forms

Here you will find many of the forms we use in our practice. As a convenience and time savings, please complete and print out all of the forms that may pertain to you and bring them to your appointment.

New Patient Forms


New patients who need their medical records from your previous provider(s) transferred, please fill out this form.


Release of Information – Obtaining copies of your Rappahannock Family Physician record

Rappahannock Family Physicians has partnered with Record Reproduction Services to handle all medical record requests. To request your medical records, please complete the Medical Records release form found at the link below:

Submit the completed Medical Release Form by one of the following methods:


Fax: 484-468-1247

Mail: 600 North Jackson St., Suite 104, Media, PA 19063

In Person: Drop the completed form off at your doctor’s office


Records will be sent within 48 hours of the receipt of the request via the delivery method indicated.