Instructions:
Please download the form and return it by one of the following methods:

1. Email: Send the completed form along with a photo ID and images of the front and back of all insurance cards to fairfieldpsychological@gmail.com

2. Fax: Fax all documents to 757-467-9560

3. In Person: Drop off the completed form, photo ID, and insurance cards at our office during business hours:
   Monday–Friday, 9 AM – 5 PM
   5265 Providence Rd, Suite 500/501
   Virginia Beach, VA 23464