Patient Eligibility/Forms

Patient Forms

Forms for New Patients:

(If you are not at BHMC patient and need to be seen for a Sports Physical or an Urgent Care Visit ONLY, please scroll to other forms)

Welcome Letter (for your reference)

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Health History Form

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Patient Registration Form | Brock Hughes

Patient Registration Forms

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Consent to Share Medical Information HIPAA| Brock Hughes

Acknowledgements and Authorizations Form | Brock Hughes

Medication Assistance Program Waiver | Brock Hughes

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Other Forms:

CONTACT US TODAY

Address:

450 West Monroe Street

Wytheville, VA 24382

Phone:

(276)-223-0558

Fax:

(276)-223-0015

Email:

info@brockhughes.org

Clinic Hours:

Monday-Thursday

8:00a.m. - 4:30p.m.

Friday

8:00a.m. - 1:00 p.m.

Saturday-Sunday

CLOSED

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BHMC earned a 2026 Gold Rating from the National Association of Free & Charitable Clinics (NAFC) Quality Standards Program

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The Mission of Brock Hughes Medical Center is to provide affordable, compassionate, and high-quality medical, pharmaceutical, and preventive health care services to the uninsured and insured residents of Wythe and Bland Counties.

Patient Forms

Forms for New Patients:

Welcome Letter (for your reference)

Notice of Privacy (for your reference)

Health History Form

Patient Registration Forms

Consent to Share Confidential Information-HIPAA General Consent

Acknowledgements and Authorizations Form

Medication Assistance Program Waiver

Additional Forms for Uninsured Patients ONLY

Other Forms:

Urgent Care/Sports Physical Registration Form

VHSL Sports Physical Form

CONTACT US TODAY

450 West Monroe Street

Wytheville, VA 24382

Faces of Humanity

Nature's Symphony