If you are visiting OrthoVirginia (Richmond) for the first time, or if your information has changed since your last visit, please complete these forms:
NOTE: To comply with federal regulations and to ensure the accuracy of our records, we require every patient to update her/his Patient History at least once every 12 months. Other forms updates may be requested as needed. We apologize for any inconvenience this may cause, but we appreciate your understanding and compliance.
OrthoVirginia (Richmond) patients please complete the following forms as needed or as directed by your physician:
Note: If you are a current or former patient of any of the following physicians needing to request medical records please complete this form and fax it back to 804-273-9294.
- William D. Brickhouse, MD
- Adam C. Crowl, MD
- Steven M. Fiore, MD
- Keith A. Glowacki, MD
- Marion M. Herring, MD
- Douglas E. Jessup, MD
- Warren B. Kirby, MD
- Cyrus S. Kump, II, MD
- T. Paul McDermott, MD
- Steven G. Reece, MD
- Jose S. Reyes, MD
- Joy V. Sharma, MD
- J. William Van Manen, MD
- Douglas A. Wayne, MD
- Kenneth R. Zaslav, MD
To request your medical records from OrthoVirginia, please complete the authorization form above and either mail or fax to listed information below.
We do use the services of BACTES to process our medical records request. There is also a charge for release of information.
Per Code of VA § 8.01-413 applies
- Pages 1-50 = $ 0.50 each page
- Pages 51 & above = 0.25 each page
Plus all postage and handling cost.
Any questions about your request or invoice can be answered by calling BACTES Imaging at (877) 270-4365
Forward request to:
Attn: Medical Records Dept.
1115 Boulders Parkway, Suite 200
North Chesterfield, VA 23225
Fax: (804) 330-2439
Forms by Physician
To access the necessary forms, please find your doctor’s name in the list below and then click on the name of the form. If your doctor is not listed here, then you may be asked to complete additional forms on the day of your visit.
Dr. Joseph Kim: Pain Form
Dr. Paul Kiritsis: Knee Survey / Shoulder Survey
Dr. Rick Placide: Back Form
Dr. Charles Vokac: Pain Form
Dr. Chris Young and Dr. Matthew Walker: Shoulder Assessment Form
Dr. Jay Desai: Hand Assessment Form
Dr. J.E.B. Stuart: Post-Operative Instructions