Bland County Medical Clinic - Permission to Contact

Patient Enrollment - Information Request: Bland County Medical Clinic works with Virginia Insurance Partners to help our patients navigate Medicare and health plan options. By completing this form, you are giving a licensed agent permission to contact you to discuss your coverage.

First Name *

Last Name *

Phone *

Secondary/Home Contact Number

Clinic Patient Address *

Email *

Receptionist Name *

Internal Staff Notes

By checking this box, I consent to receive non-marketing text messages from VA Insurance Partners regarding appointment reminders, healthcare updates, and enrollment status. Message frequency varies; message & data rates may apply. Text HELP for assistance, or reply STOP to opt out.

By checking this box, I consent to receive marketing and promotional messages, including special offers, new service updates, and healthcare newsletters from Virginia Insurance Partners LLC at the phone number provided. Consent is not a condition of service. Message frequency varies; message & data rates may apply. Text HELP for assistance, or reply STOP to opt out.