For the latest COVID-19 information, visit vcuhealth.org/covid-19 or Children’s Hospital of Richmond at VCU for pediatrics. For vaccine details, visit vcuhealth.org/covidvaccine.


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Patient Forms

New patient paperwork

We want to make every aspect of your visit with us as convenient as possible. Below you will find all necessary registration forms required for you first visit. Please complete the forms and bring them with you to your appointment.

Patient Satisfaction Survey

We here at Chase City Primary Care Center strive to offer you the highest quality in healthcare and patient satisfaction. We value your opinion and would like to know how you feel about the services that you received with us. Please help us to serve you better by completing the Customer Satisfaction Survey provided. Your responses are directly responsible for the improvement of our services to you. All responses are kept confidential and anonymous.

Medical Records Release

If you are in need of a copy of your medical records, please complete the attached medical record release form. You can also complete this form if you have records that you would like Chase City Primary Care to obtain from another provider.

Payment Agreements

We understand that everyone suffers from financial strain and difficulty from time to time. That is why we offer payment agreements as needed. If you need to set up a payment agreement with us, please call or stop by the office to discuss your options.

For self-pay patients, those that do not have any insurance coverage, we require a minimum deposit of $50 at the time of your initial visit. We also ask that you establish a payment agreement with us at this time.

If you are a VCU Health CMH team member we offer payroll deductions. VCU Health CMH team members are also eligible for prompt pay discounts. Please speak to the office manager to establish a payroll deduction or discuss prompt pay discounts.