Please complete and bring the following forms to your first appointment:
- Thermography Intake Form
- Full Body Study Questionnaire
- Breast Thermography Confidential Questionnaire
- Authorization to Use or Disclose Protected Health Information
IMPORTANT NOTE: The Thermography Center of Fairfax, The Thermography Centers of Virginia, and all its partner clinics are cash practices. Therefore, we do not submit to insurance companies for “out of network” benefits. If reimbursement is sought, many insurance companies require your General Practitioner or Medical Professional provide a diagnosis code to give justification for the diagnostic test. Please contact your physician before you submit for reimbursement. A treatment code has been provided for processing CPT#93740.