What to Bring:
Please print and complete the appropriate form(s). Bring the completed forms with you to your appointment.
- Forms for New Adult Patients:
- Forms for New Pediatric Patients:
You Will Also Need to Bring:
- Insurance Card (if applicable)
- Sliding Fee Form (if applicable)
- Get Form (PDF)
- Get Form (Word Document)
- SDHS, Inc. is a Federally Qualified Health Center(FQHC) which allows us to offer a Sliding Scale Discount to qualifying patients. The Sliding fee discount is based on household income and number of dependents in the household.
Notice of Privacy Practices:
Click HERE to view this notice describes how information about you may be used and disclosed and how you can get access to this information.
Patient Bill of Rights
The Board of Directors and Staff of Southern Dominion Health System, Inc. (SDHS) respect your rights as a patient and recognize that you are an individual with unique health care needs. We want you to know your rights as a patient as well as your obligations to yourself, other patients, your provider of care and this organization. Please click HERE to read your rights.
Southern Dominion Health System, Inc offers a sliding fee program to its patients. This program offers a discount for medical, dental, and behavioral health services. Income eligibility and family size are required when you apply to determine if you and your family qualify. Ask one of our front desk employees about the sliding fee program and how it can help you.