Patient Communication Information

Blue Ridge Pediatrics, LLP

Please correct the errors described below.

In order for us to better communicate with our patients we are asking all patients to fill out this Patient Communication log.

When we activate your email address you will receive an email confirmation from us. This will include the link to our portal, your log in and your password. If you forgot your log in and/or password the Receptionist can reset your password for you today

How would you like us to confirm your appointment? You can select one or both.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Your information will be encrypted.