{"id":204,"date":"2019-07-26T12:41:02","date_gmt":"2019-07-26T16:41:02","guid":{"rendered":"https:\/\/virginiahearingcenter.fm1.dev\/patient-forms\/"},"modified":"2020-01-29T18:07:38","modified_gmt":"2020-01-29T23:07:38","slug":"patient-forms","status":"publish","type":"page","link":"https:\/\/virginiahearingcenter.com\/resources\/patient-forms\/","title":{"rendered":"Patient Forms"},"content":{"rendered":"\n<table class=\"download-table\"><tr>\r\n\t\t\t\t\t\t\t\t\t<td><svg aria-hidden=\"true\" role=\"img\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 384 512\"><path fill=\"currentColor\" d=\"M369.9 97.9L286 14C277 5 264.8-.1 252.1-.1H48C21.5 0 0 21.5 0 48v416c0 26.5 21.5 48 48 48h288c26.5 0 48-21.5 48-48V131.9c0-12.7-5.1-25-14.1-34zm-22.6 22.7c2.1 2.1 3.5 4.6 4.2 7.4H256V32.5c2.8.7 5.3 2.1 7.4 4.2l83.9 83.9zM336 480H48c-8.8 0-16-7.2-16-16V48c0-8.8 7.2-16 16-16h176v104c0 13.3 10.7 24 24 24h104v304c0 8.8-7.2 16-16 16zm-22-171.2c-13.5-13.3-55-9.2-73.7-6.7-21.2-12.8-35.2-30.4-45.1-56.6 4.3-18 12-47.2 6.4-64.9-4.4-28.1-39.7-24.7-44.6-6.8-5 18.3-.3 44.4 8.4 77.8-11.9 28.4-29.7 66.9-42.1 88.6-20.8 10.7-54.1 29.3-58.8 52.4-3.5 16.8 22.9 39.4 53.1 6.4 9.1-9.9 19.3-24.8 31.3-45.5 26.7-8.8 56.1-19.8 82-24 21.9 12 47.6 19.9 64.6 19.9 27.7.1 28.9-30.2 18.5-40.6zm-229.2 89c5.9-15.9 28.6-34.4 35.5-40.8-22.1 35.3-35.5 41.5-35.5 40.8zM180 175.5c8.7 0 7.8 37.5 2.1 47.6-5.2-16.3-5-47.6-2.1-47.6zm-28.4 159.3c11.3-19.8 21-43.2 28.8-63.7 9.7 17.7 22.1 31.7 35.1 41.5-24.3 4.7-45.4 15.1-63.9 22.2zm153.4-5.9s-5.8 7-43.5-9.1c41-3 47.7 6.4 43.5 9.1z\"><\/path><\/svg> <a href=\"https:\/\/virginiahearingcenter.com\/wp-content\/uploads\/2020\/01\/bec_patient_information_form_interactive-1.pdf\"  target=\"_blank\">Patient Information<\/a><\/td>\r\n\t\t\t\t\t\t\t\t\t<td><a href=\"https:\/\/virginiahearingcenter.com\/wp-content\/uploads\/2020\/01\/bec_patient_information_form_interactive-1.pdf\"  download target=\"_blank\" class=\"button\"><svg aria-hidden=\"true\" role=\"img\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 384 512\"><path fill=\"currentColor\" d=\"M360 480H24c-13.3 0-24-10.7-24-24v-24c0-13.3 10.7-24 24-24h336c13.3 0 24 10.7 24 24v24c0 13.3-10.7 24-24 24zM128 56v136H40.3c-17.8 0-26.7 21.5-14.1 34.1l152.2 152.2c7.5 7.5 19.8 7.5 27.3 0l152.2-152.2c12.6-12.6 3.7-34.1-14.1-34.1H256V56c0-13.3-10.7-24-24-24h-80c-13.3 0-24 10.7-24 24z\"><\/path><\/svg><\/a><\/td>\r\n\t\t\t\t\t\t\t\t<\/tr><tr>\r\n\t\t\t\t\t\t\t\t\t<td><svg aria-hidden=\"true\" role=\"img\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 384 512\"><path fill=\"currentColor\" d=\"M369.9 97.9L286 14C277 5 264.8-.1 252.1-.1H48C21.5 0 0 21.5 0 48v416c0 26.5 21.5 48 48 48h288c26.5 0 48-21.5 48-48V131.9c0-12.7-5.1-25-14.1-34zm-22.6 22.7c2.1 2.1 3.5 4.6 4.2 7.4H256V32.5c2.8.7 5.3 2.1 7.4 4.2l83.9 83.9zM336 480H48c-8.8 0-16-7.2-16-16V48c0-8.8 7.2-16 16-16h176v104c0 13.3 10.7 24 24 24h104v304c0 8.8-7.2 16-16 16zm-22-171.2c-13.5-13.3-55-9.2-73.7-6.7-21.2-12.8-35.2-30.4-45.1-56.6 4.3-18 12-47.2 6.4-64.9-4.4-28.1-39.7-24.7-44.6-6.8-5 18.3-.3 44.4 8.4 77.8-11.9 28.4-29.7 66.9-42.1 88.6-20.8 10.7-54.1 29.3-58.8 52.4-3.5 16.8 22.9 39.4 53.1 6.4 9.1-9.9 19.3-24.8 31.3-45.5 26.7-8.8 56.1-19.8 82-24 21.9 12 47.6 19.9 64.6 19.9 27.7.1 28.9-30.2 18.5-40.6zm-229.2 89c5.9-15.9 28.6-34.4 35.5-40.8-22.1 35.3-35.5 41.5-35.5 40.8zM180 175.5c8.7 0 7.8 37.5 2.1 47.6-5.2-16.3-5-47.6-2.1-47.6zm-28.4 159.3c11.3-19.8 21-43.2 28.8-63.7 9.7 17.7 22.1 31.7 35.1 41.5-24.3 4.7-45.4 15.1-63.9 22.2zm153.4-5.9s-5.8 7-43.5-9.1c41-3 47.7 6.4 43.5 9.1z\"><\/path><\/svg> <a href=\"https:\/\/virginiahearingcenter.com\/wp-content\/uploads\/2020\/01\/bec_summary_of_financial_agreement_v3.pdf\"  target=\"_blank\">Summary of Financial Agreement<\/a><\/td>\r\n\t\t\t\t\t\t\t\t\t<td><a href=\"https:\/\/virginiahearingcenter.com\/wp-content\/uploads\/2020\/01\/bec_summary_of_financial_agreement_v3.pdf\"  download target=\"_blank\" class=\"button\"><svg aria-hidden=\"true\" role=\"img\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 384 512\"><path fill=\"currentColor\" d=\"M360 480H24c-13.3 0-24-10.7-24-24v-24c0-13.3 10.7-24 24-24h336c13.3 0 24 10.7 24 24v24c0 13.3-10.7 24-24 24zM128 56v136H40.3c-17.8 0-26.7 21.5-14.1 34.1l152.2 152.2c7.5 7.5 19.8 7.5 27.3 0l152.2-152.2c12.6-12.6 3.7-34.1-14.1-34.1H256V56c0-13.3-10.7-24-24-24h-80c-13.3 0-24 10.7-24 24z\"><\/path><\/svg><\/a><\/td>\r\n\t\t\t\t\t\t\t\t<\/tr><tr>\r\n\t\t\t\t\t\t\t\t\t<td><svg aria-hidden=\"true\" role=\"img\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 384 512\"><path fill=\"currentColor\" d=\"M369.9 97.9L286 14C277 5 264.8-.1 252.1-.1H48C21.5 0 0 21.5 0 48v416c0 26.5 21.5 48 48 48h288c26.5 0 48-21.5 48-48V131.9c0-12.7-5.1-25-14.1-34zm-22.6 22.7c2.1 2.1 3.5 4.6 4.2 7.4H256V32.5c2.8.7 5.3 2.1 7.4 4.2l83.9 83.9zM336 480H48c-8.8 0-16-7.2-16-16V48c0-8.8 7.2-16 16-16h176v104c0 13.3 10.7 24 24 24h104v304c0 8.8-7.2 16-16 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download target=\"_blank\" class=\"button\"><svg aria-hidden=\"true\" role=\"img\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 384 512\"><path fill=\"currentColor\" d=\"M360 480H24c-13.3 0-24-10.7-24-24v-24c0-13.3 10.7-24 24-24h336c13.3 0 24 10.7 24 24v24c0 13.3-10.7 24-24 24zM128 56v136H40.3c-17.8 0-26.7 21.5-14.1 34.1l152.2 152.2c7.5 7.5 19.8 7.5 27.3 0l152.2-152.2c12.6-12.6 3.7-34.1-14.1-34.1H256V56c0-13.3-10.7-24-24-24h-80c-13.3 0-24 10.7-24 24z\"><\/path><\/svg><\/a><\/td>\r\n\t\t\t\t\t\t\t\t<\/tr><tr>\r\n\t\t\t\t\t\t\t\t\t<td><svg aria-hidden=\"true\" role=\"img\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 384 512\"><path fill=\"currentColor\" d=\"M369.9 97.9L286 14C277 5 264.8-.1 252.1-.1H48C21.5 0 0 21.5 0 48v416c0 26.5 21.5 48 48 48h288c26.5 0 48-21.5 48-48V131.9c0-12.7-5.1-25-14.1-34zm-22.6 22.7c2.1 2.1 3.5 4.6 4.2 7.4H256V32.5c2.8.7 5.3 2.1 7.4 4.2l83.9 83.9zM336 480H48c-8.8 0-16-7.2-16-16V48c0-8.8 7.2-16 16-16h176v104c0 13.3 10.7 24 24 24h104v304c0 8.8-7.2 16-16 16zm-22-171.2c-13.5-13.3-55-9.2-73.7-6.7-21.2-12.8-35.2-30.4-45.1-56.6 4.3-18 12-47.2 6.4-64.9-4.4-28.1-39.7-24.7-44.6-6.8-5 18.3-.3 44.4 8.4 77.8-11.9 28.4-29.7 66.9-42.1 88.6-20.8 10.7-54.1 29.3-58.8 52.4-3.5 16.8 22.9 39.4 53.1 6.4 9.1-9.9 19.3-24.8 31.3-45.5 26.7-8.8 56.1-19.8 82-24 21.9 12 47.6 19.9 64.6 19.9 27.7.1 28.9-30.2 18.5-40.6zm-229.2 89c5.9-15.9 28.6-34.4 35.5-40.8-22.1 35.3-35.5 41.5-35.5 40.8zM180 175.5c8.7 0 7.8 37.5 2.1 47.6-5.2-16.3-5-47.6-2.1-47.6zm-28.4 159.3c11.3-19.8 21-43.2 28.8-63.7 9.7 17.7 22.1 31.7 35.1 41.5-24.3 4.7-45.4 15.1-63.9 22.2zm153.4-5.9s-5.8 7-43.5-9.1c41-3 47.7 6.4 43.5 9.1z\"><\/path><\/svg> <a href=\"https:\/\/virginiahearingcenter.com\/wp-content\/uploads\/2020\/01\/bec_physician_referral_form_fillable_v1-1.pdf\"  target=\"_blank\">Physician Referral Form<\/a><\/td>\r\n\t\t\t\t\t\t\t\t\t<td><a href=\"https:\/\/virginiahearingcenter.com\/wp-content\/uploads\/2020\/01\/bec_physician_referral_form_fillable_v1-1.pdf\"  download target=\"_blank\" class=\"button\"><svg aria-hidden=\"true\" role=\"img\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 384 512\"><path fill=\"currentColor\" d=\"M360 480H24c-13.3 0-24-10.7-24-24v-24c0-13.3 10.7-24 24-24h336c13.3 0 24 10.7 24 24v24c0 13.3-10.7 24-24 24zM128 56v136H40.3c-17.8 0-26.7 21.5-14.1 34.1l152.2 152.2c7.5 7.5 19.8 7.5 27.3 0l152.2-152.2c12.6-12.6 3.7-34.1-14.1-34.1H256V56c0-13.3-10.7-24-24-24h-80c-13.3 0-24 10.7-24 24z\"><\/path><\/svg><\/a><\/td>\r\n\t\t\t\t\t\t\t\t<\/tr><tr>\r\n\t\t\t\t\t\t\t\t\t<td><svg aria-hidden=\"true\" role=\"img\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 384 512\"><path fill=\"currentColor\" d=\"M369.9 97.9L286 14C277 5 264.8-.1 252.1-.1H48C21.5 0 0 21.5 0 48v416c0 26.5 21.5 48 48 48h288c26.5 0 48-21.5 48-48V131.9c0-12.7-5.1-25-14.1-34zm-22.6 22.7c2.1 2.1 3.5 4.6 4.2 7.4H256V32.5c2.8.7 5.3 2.1 7.4 4.2l83.9 83.9zM336 480H48c-8.8 0-16-7.2-16-16V48c0-8.8 7.2-16 16-16h176v104c0 13.3 10.7 24 24 24h104v304c0 8.8-7.2 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aria-hidden=\"true\" role=\"img\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 384 512\"><path fill=\"currentColor\" d=\"M360 480H24c-13.3 0-24-10.7-24-24v-24c0-13.3 10.7-24 24-24h336c13.3 0 24 10.7 24 24v24c0 13.3-10.7 24-24 24zM128 56v136H40.3c-17.8 0-26.7 21.5-14.1 34.1l152.2 152.2c7.5 7.5 19.8 7.5 27.3 0l152.2-152.2c12.6-12.6 3.7-34.1-14.1-34.1H256V56c0-13.3-10.7-24-24-24h-80c-13.3 0-24 10.7-24 24z\"><\/path><\/svg><\/a><\/td>\r\n\t\t\t\t\t\t\t\t<\/tr><\/table>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":113,"menu_order":36,"comment_status":"closed","ping_status":"closed","template":"","meta":{"schema":"","fname":"","lname":"","position":"","credentials":"","placeID":"","no_match":false,"name":"","company":"","review":"","address":"","city":"","state":"","zip":"","lat":"","lng":"","phone1":"","phone2":"","fax":"","mon1":"","mon2":"","tue1":"","tue2":"","wed1":"","wed2":"","thu1":"","thu2":"","fri1":"","fri2":"","sat1":"","sat2":"","sun1":"","sun2":"","hours-note":"","footnotes":""},"class_list":["post-204","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v24.1 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Patient Forms - Virginia Hearing Center<\/title>\n<meta name=\"description\" content=\"(804) 288-3277 |\" \/>\n<meta name=\"robots\" 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