Patient Forms

Please complete and bring the following forms to your first appointment:

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.

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