PATENT INFORMATION FORM

PATIENT NAME:  LAST___________________FIRST________________MI___

NAME YOU PREFER TO BE CALLED__________________________________

PATIENT ADDRESS_________________________________________________

CITY_____________________________STATE_________ZIP_______________

HOME PHONE_____________________CELL____________________________

E-MAIL____________________________________________________________

BIRTH DATE_____________________AGE______SEX   M      F

EMPLOYMENT INFORMATION

PATIENT EMPLOYER________________________OCCUPATION___________

EMPLOYER ADDRESS_______________________________________________

CITY___________________________________STATE_______ZIP___________

WORK PHONE NO__________________________EXTENSION_____________

IN CASE OF EMERGENCY

NAME___________________________________RELATIONSHIP____________

PHONE__________________________________

PATIENT'S SPOUSE_______________________PHONE____________________

FAMILY PHYSICIAN______________________PHONE____________________

HOW DID YOU HEAR ABOUT OUR PRACTICE:

INTERNET_____YELLOW PAGES_____

PHYSICIAN (PLEASE NAME) ________________________________________

FRIEND (PLEASE NAME)____________________________________________

OTHER (PLEASE NAME)_____________________________________________

Nova ABC Weight Loss Center requires a $75 deposit to reserve an initial appointment with the doctor.  This charge will be applied to your first visit; or is fully refundable as long as the office is given no less than 24 hours notice of cancelation.  IF YOU ARE CALLING TO CANCEL AFTER HOURS.  YOU CAN LEAVE A MESSAGE ON THE MACHINE BY DIALING 703-494-1020 AND PRESSING #8

In addition, there will be a $50 charge in the event that a patient makes and cancels the first appointment and then reschedules a second appointment and fails to keep that second appointment.  In this event the 24 hour rule is waived.  YOU MUST KEEP THE SECOND APPOINTMENT IN ORDER TO AVOID THE $50 CHARGE.  THERE WILL BE NO EXCEPTIONS TO THIS RULE.

Due to federal regulations, we can not see any patient with Medicaid insurance.  Please sign to acknowledge that you are NOT currently on Medicaid and in the event that you are enrolled in Medicaid you will notify us immediately.  We are sorry of any inconvenience this may cause. 

We offer prepaid weekly and bi-weekly visits at a discounted rate THESE VISITS EXPIRE, the weekly prepaid visits are good for 5 weeks and the biweekly are good for 6 weeks. 

I have read and understand the above and agree to these terms.

______________________             _______________

SIGNATURE                                   DATE

FIRST APPOINTMENT REQUIREMENTS

LABWORK         CMP, CBC, LIPID PANEL, FREE T4, URIC ACID, TSH, PHOS

PREP FOR METABOLIC TEST:

NO EXERCISE OF CAFFEINE THE DAY OF THE APPOINTMENT

4 HOUR FAST (NOTHING BUT WATER) PRIOR TO THE TEST