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Ladysmith Urgent Care

Dr. Sudhir Gulati, M.D.
17428-E Center Drive
Ruther Glen, VA 22546
804-448-4885 - Phone
804-448-4886 - Fax


Forms
New Patient Information Form - Please print, fill out and bring this form with you when visiting our office. This form is for new patients or if you're an existing patient and your address and/or insurance information has changed.

Medical History Form - Please print, fill out and bring this form with you when visiting our office. This form goes with the New Patient Information Form.

Patient Authorization Form - Please print, fill out and bring this form with you when visiting our office. This form also goes with the New Patient Information Form.

Patient Acknowledgement for Notice of Privacy Practice

Patient Satisfaction Survey - Please print and fill out after your visit. You may either fill it out in the office after your visit and leave it with the receptionist or mail it in at a later time. We appreciate your feedback.

The forms listed above are in .pdf format. If you do not have Acrobat Reader, you can download your free copy here.