Please complete this form in its entirety, as all information is needed to register for VA health care.
Return it to: Once complete, return this form to your site's VA Liaison for Healthcare.
Patient sections: Patient Personal Information, Patient Military Service History, Patient Military Discharge Information.
Branch of service: Army, Navy, Air Force, Marine Corps, Coast Guard, Space Force.
Care requested: Primary Care, Mental Health, Specialty Care, Medication.
| Question | Answer |
|---|---|
| Form Name | VA Form 10-0454 |
| Form Length | 2 pages |
| Fillable? | Yes |
| Fillable fields | 60 |
| Avg. time to fill out | 10 min |
| Edition | JUL 2026 |
| Where to return | Your site's VA Liaison for Healthcare |
| Matches the agency's file | Yes, checked October 1, 2026 |
| Other names | VA Form 10-0454, 10-0454, VA 10-0454, VA 10 0454, VA Liaison for Healthcare Referral Form |
| Official source | VA Form 10-0454 (Rev JUL 2026), Department of Veterans Affairs |
Va Form 10 0454 isn’t the one you’re looking for?