PATENT INFORMATION FORM
PATIENT NAME: LAST___________________FIRST________________MI___
BIRTH DATE_____________________AGE______SEX M F
WORK PHONE NO__________________________EXTENSION_____________
IN CASE OF EMERGENCY
HOW DID YOU HEAR ABOUT OUR PRACTICE:
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 hour's 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.
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.
FIRST APPOINTMENT REQUIREMENTS
PLEASE DO NOT WEAR ANY OILS, LOTIONS, OR CREAM THE DAY OF THE TEST
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