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* 1. Date of scheduled appointment

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* 2. Select the location of your scheduled appointment:

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* 3. Full Name

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* 4. Date of Birth

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* 5. What are your pronouns?

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* 6. Home/Mailing Address

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* 7. Cell Phone Number (enter NA in none)

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* 8. Home Phone Number (enter NA if none)

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* 9. Work Phone Number (enter NA if none)

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* 10. Email Address (enter NA if none)

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* 11. Preferred method of communication

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* 12. Emergency Contact - name and relationship

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* 13. Emergency Contact - phone number

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* 14. Employer (enter NA if none)

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* 15. Occupation (enter NA if none)

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* 16. IMPORTANT POLICIES OF THE CENTERS FOR VULVOVAGINAL DISORDERS

I. Your First Appointment:
New patient appointments are approximately 1 hour and thirty minutes, but we ask that you set aside 2 hours in the event that your appointment requires more time. If English is not your primary language, we advise you to bring someone with you to translate and assist you throughout the appointment, as needed. Please contact our website for our address and directions to our offices: www.cvvd.org.

II. Your Providers and Care Team:
Our providers are faculty members at The George Washington University School of Medicine and are considered world-renowned experts on vulvar disease. As such, we frequently have visiting health care providers shadowing our physicians to learn from us and spread awareness. You reserve the right to refuse to allow them to be present during your visit.

*Please note that some of our providers have a scribe present throughout the entire appointment to detail your comprehensive visit. These scribes are employees of CVVD. Our scribes handle the note-taking and box-ticking of modern-day medicine, allowing our providers to have more face-to-face time with the patient.

III. Require Paperwork:
The Vulvar Pain Questionnaire AND Registration form must be completed no later than one week prior to the visit. Our providers will not consult with or examine you unless you have completed these medical intake forms. Both documents can be found on our website at www.cvvd.org/contact.

*Your provider will review the answers to your questionnaire and may ask additional questions during your appointment. This confidential questionnaire will become part of your medical record. This data may be tabulated (without your name) in the course of research studies to learn which factors seem most important in evaluating other patients with these similar problems. In addition, you may have photographs of your genitalia taken during this visit BUT you may refuse consent.

By signing below, you attest that you understand and agree to the above policies:

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* 17. PAYMENT POLICY

Our policy is that payment is to be made at the time services are rendered. Whether or not your insurance pays in full, a portion or nothing at all for services is a matter between you and your insurance carrier. Payment is accepted in the form of cash, check, money order, or credit card. The patient agrees to pay a $250 cancellation fee if the appointment is not canceled or rescheduled 2 business days prior to your appointment time.
*We do not accept CareCredit.

Cancellation Policy:
CVVD requires two business days notice if you need to cancel or reschedule a new patient or follow-up appointment. The fee for any appointment cancelled without giving two business days notice is $250.00, no exceptions.

**Please note: CVVD is not responsible for any costs that you incur as a result of the cancellation or rescheduling of your appointment including (but not limited to) flight cancellation/change fees, hotel cancellation/change fees, or lost wages. As such, we STRONGLY encourage you to get FULLY REFUNDABLE tickets and/or reservations.

Insurance and Payment Policy:
CVVD offers patients comprehensive health care which limits our ability to work within the limitations of the health insurance industry. Due to this, we do not accept insurance, Medicaid, Medicare, or Tricare nor do we accept assignment, file, or coordinate insurance reimbursements. We will provide you with an itemized receipt that you may use to file with your claim for reimbursement.

All labwork performed during the visit will be sent to Sunrise Laboratories for processing. We will provide them with your insurance information so that they can process/bill your labwork through your insurance company. If you are uninsured or if your insurance does not cover/partially covers lab costs, Sunrise Laboratories will contact you directly to collect payment.

Appointment Cost:
The cost for a new patient appointment at our Washington, DC location is $1650.00 (consult, exam; therapeutic treatments and interventions may be additional). Our NY office charges a flat fee of $1800 for new patients seeing Dr. Andrew Goldstein (consult, exam; therapeutic treatments and interventions may be additional). Payment, in full, is required at the time of service. We accept all major credit cards, cash, and checks (from a US banking institution).
*We do not accept CareCredit.

By signing below, you attest that you understand and agree to the above payment policies:

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* 18. Please provide your insurance information in the space below (enter N/A if none) OR upload your insurance card (skip to questions 18 and 19).
This information provided to Sunrise Laboratories for specimen processing. If you do not have insurance, Sunrise Laboratories will bill you directly.

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* 19. Please upload an image of your insurance card. (FRONT). This information will be used to charge your lab test. 

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* 20. Please upload an image of your insurance card. (BACK)

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