Connect Health + Wellness
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Connect Health + Wellness
Home
Patients
  • New Patients
  • Forms
  • Schedule Online
  • Patient Portal
  • Pay Online
  • Sliding Fee Program
Services
  • Our Services
  • Medical Care
  • Dental Care
  • Behavioral Health
  • Medication Assistance
  • Mammography Assistance
  • Eye Exams
  • Insurance Assistance
  • Health Education
Locations
  • Our Locations
  • Bassett
  • Ridgeway
  • Patrick Springs
  • Dental
  • Mobile Health
  • Administrative Offices
About
  • About Us
  • Contact Us
  • Board of Directors
  • FAQs
News & Events
  • News
  • Events
Careers
  • Job Openings
More
  • Home
  • Patients
    • New Patients
    • Forms
    • Schedule Online
    • Patient Portal
    • Pay Online
    • Sliding Fee Program
  • Services
    • Our Services
    • Medical Care
    • Dental Care
    • Behavioral Health
    • Medication Assistance
    • Mammography Assistance
    • Eye Exams
    • Insurance Assistance
    • Health Education
  • Locations
    • Our Locations
    • Bassett
    • Ridgeway
    • Patrick Springs
    • Dental
    • Mobile Health
    • Administrative Offices
  • About
    • About Us
    • Contact Us
    • Board of Directors
    • FAQs
  • News & Events
    • News
    • Events
  • Careers
    • Job Openings
  • Home
  • Patients
    • New Patients
    • Forms
    • Schedule Online
    • Patient Portal
    • Pay Online
    • Sliding Fee Program
  • Services
    • Our Services
    • Medical Care
    • Dental Care
    • Behavioral Health
    • Medication Assistance
    • Mammography Assistance
    • Eye Exams
    • Insurance Assistance
    • Health Education
  • Locations
    • Our Locations
    • Bassett
    • Ridgeway
    • Patrick Springs
    • Dental
    • Mobile Health
    • Administrative Offices
  • About
    • About Us
    • Contact Us
    • Board of Directors
    • FAQs
  • News & Events
    • News
    • Events
  • Careers
    • Job Openings

Forms

A clerk handing someone a paper

New Patient Forms

If you are interested in becoming a patient at Connect Health + Wellness, we are welcoming new patients at Bassett, Ridgeway, Patrick Springs and Dental. If you would like to complete new patient paperwork prior to your visit, you may do so below. Once complete, return them to the front desk of the clinic where you'd like to be seen and we will get you established as a new patient and get you scheduled for an appointment. If you have any questions, please don't hesitate to call us at 

276-638-0787. 


Prefer to schedule an appointment online? Click here to schedule online.

New Patient Forms

Click on each document below, print, complete each form and return to the clinic.

CHW New Pt Welcome Ltr Oct 2024 (pdf)Download
CHW Cancellation Notice Nov 2024 (pdf)Download
CHW Patient Demographics Mar 2025 (pdf)Download
CHW New Sliding Fee Discount Program (Mar 2025) (pdf)Download
CHW History Questionnaire (pdf)Download
CHW Hardship Policy and Application (pdf)Download
CHW Consent to Treat Feb 2024 (pdf)Download
CHW MedAssist Info Feb 2024 (pdf)Download
CHW Notice of Privacy Practices (pdf)Download
CHW Portal Guidelines (pdf)Download

Nuevos formularios para pacientes

Haga clic en cada documento a continuación, imprima y complete cada formulario para regresar.

Spanish CHW New Pt Welcome Ltr Mar 2024 (pdf)Download
Spanish - CHW Cancellation Notice Agreement (pdf)Download
Spanish CHW Patient Demographic Feb 2025 (pdf)Download
Spanish CHW New Sliding Fee Discount Program (Mar 2025) (pdf)Download
Spanish CHW History Questionnaire (pdf)Download
Spanish CHW Hardship Policy and Application (pdf)Download
Spanish CHW Consent to Treat (pdf)Download
Spanish CHW MedAssist Info Mar 2024 (pdf)Download
Spanish CHW Notice of Privacy Practices (pdf)Download
Spanish CHW Portal Guidelines (pdf)Download
  • New Patients
  • Schedule Online
  • Patient Portal
  • Pay Online
  • Our Services
  • Medical Care
  • Our Locations
  • About Us
  • News

Connect Health + Wellness

29 Jones St. Martinsville, VA 24112

276-638-0787

info@connecthealthva.org


ACCESSIBILITY   DISCLAIMER   NONDISCRIMINATION NOTICE    LANGUAGE ASSISTANCE SERVICES

Español | 한국어 | Tiếng Việ | 繁體中文 | العربية | Tagalog | فارسی | አማርኛ | اُردُو | Français | Русский | हिंदी | Deutsch | বাংলা | Ɓàsɔ́ɔ̀-wùɖù-po-nyɔ̀ | Igbo asusu | èdè Yorùbá

This health center is a Health Center Program grantee under 24 U.S.C. 254b, and a deemed Public Health Service employee under 42 U.S.C. 233(g)-(n). This health center receives 

HHS funding and has Federal Public Health Service (PHS) deemed status with respect to certain health or health-related claims, including medical malpractice claims, for itself and 

its covered individuals.

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