Please complete this form for a quick and convenient way to schedule an initial appointment at Bradley Free Clinic. Upon completion, your information will be automatically emailed to us and you will be contacted within 24 hours during the work week.
*You will be asked to sign this form upon arrival to your appointment for the agreement on the below statements.*
Consent to Treatment: By submitting this form, I hereby authorize the physicians, nurse practitioners, dentists, nurses, and/or other medical providers working at the Bradley Free Clinic to examine and/or treat me/or my dependent and/or to access medications and/or provide invasive/non-invasive medical procedures, if needed. I also understand that all health care providers who volunteer at the Bradley Free Clinic are exempt from liability.
Deemed Consent for Blood Testing: Virginia State law states that when a healthcare worker is exposed to the body fluids of another person, the patient shall be deemed to have consented to testing and to the release of the results to the exposed person and the local health department.
Release of Information: I authorize the Bradley Free Clinic to both release and request information to/from any physician or other health care professional involved in my/the patient’s treatment. I further authorize release of information to any health care facility to which I/the patient may be discharged or transferred to for treatment.