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 Centers of Fairfax is a cash practice. 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.