• Facebook
  • Twitter

Countryside Orthopaedics

Orthopedic Surgeons & Specialists in Loudoun

703-858-1800

19465 Deerfield Avenue, Suite 405, Leesburg, VA 20176

  • Home
  • About
    • Reviews
    • Physicians
      • Imran Khan, M.D.
      • Raymond Lower, D.O., F.A.A.O.S.
    • Physician Assistants
    • Physical/Hand/OT Therapists
    • Orthopaedic Technicians
  • Services
    • Hand Therapy
    • Physical Therapy
    • Surgery
      • Before Your Surgery
      • After Your Surgery
  • Resources
    • Patient Forms
    • Financial Policy
    • Prescription Refills
    • Pay Online
    • Patient Education
    • Medical Records
    • Durable Medical Equipment
    • Worker’s Comp
    • Medical Insurances
  • News
  • Contact
  • TeleHealth
  • Pay Online

Patient Forms

All new patients and established patients who have not been seen in the last twelve (12) months are required to update the patient forms below. If you have an upcoming appointment, you may complete the following forms and bring them with you to your appointment.

  • Patient Registration Forms (2 pages)
  • Patient Medical History
  • Patient Medication List
  • Quick Dash Form – Dr. Khan’s patients and all hand therapy patients
  • HIPAA Privacy Practices
  • Patient Financial Policy
  • Notice of Privacy Practices Acknowledgement

Please Note: To fill out these PDF forms on your computer, please download the latest free Adobe Acrobat Reader application.

Patients should also bring the following:
  • Referral forms as required by your health insurance plan. It is your responsibility to ensure you understand and have complied with your insurance provider’s policies. If you do not have your referral at the time of your appointment you will either (1) be responsible for services provided; or (2) be required to reschedule your appointment until such time as you have proper authorization as required by your policy.
  • Current insurance cards will speed up payment of your claim. Updated cards may contain important changes that affect your coverage. We will also ask for a photo ID such as your driver’s license.
  • Resources to pay for co-payments and for other services not covered by your insurance. We accept cash, check, and Discover, MasterCard and VISA.
  • Uninsured patients should be prepared to pay for their initial office visit. Please call our office in advance of your appointment to determine the amount that will be due.
  • Copies or originals of previous X-rays and reports will save you money and prevent unnecessary radiation exposure.
  • Please bring along any orthotics, braces, or walking aids you routinely use.
Additional forms:
  • Authorization to Release Healthcare Information Form
  • Workers’ Comp Form
  • Credit Card Authorization Form

Please Note: To fill out these PDF forms on your computer, please download the latest free Adobe Acrobat Reader application.

Contact Us

Orthopaedic Office: 703-858-1800
Therapy Office: 703-858-1805

Countryside Orthopaedics
19465 Deerfield Avenue, Suite 405
Leesburg, VA 20176
Fax: 703-858-1801

Serving the greater Loudoun County area, including Purcellville VA, Leesburg VA, Ashburn VA and Sterling VA.

Our orthopaedic office is open from 8:00 AM to 4:30 PM, Monday through Friday, and are closed each day from 12 Noon to 1:30 PM for lunch.

Our therapy office is open from 7:00 AM to 7 PM, Monday through Friday.

  • Facebook
  • Twitter
Pay Online

© Copyright 2016 Countryside Orthopaedics. All Rights Reserved.

Website SEO and Marketing by MarketSpark Digital Marketing • Admin
▲