4012 Raintree Road, Suite 200A
Chesapeake, VA 23321
(757) 488-2223

Monday - Thursday 8AM - 6PM
Friday 8AM - 5PM
Saturday (Walk-ins) 9AM - 11AM

We offer same day appointments for sick patients.

Forms

The following forms to be filled out by a provider require the child to have had a well child check up in the last twelve months:

  • School/Daycare Physical Forms
  • Sports Physical Forms
  • Administration of Medication Forms
  • WIC Forms
  • FMLA Forms

Medical Records
When requesting a child’s medical records the following may apply. Click here to request records be sent to Renaissance or for Renaissance to send records to another facility.  Charges may apply when requesting records.

Immunization records and visit summaries are available for free on the portal. 

New Patient Information Packet :

All New Patient Forms

Patient History Form
Patient Information Form
Medical Care Authorization Form
Financial Policy Form

HIPAA Paperwork

Invitation Letter

 

Attention Deficit Parent and Teacher Forms (pdf format)

Parent Informant
Teacher Informant
Follow-up Parent Informant
Follow-up Teacher Informant

Employment Application

Employment Application PDF

 

 

In order to view or print these forms you will need Adobe Acrobat Reader installed. Click here to download it.