* 1. Date of scheduled appointment

* 2. Select the location of your scheduled appointment:

* 3. Full Name

* 4. Date of Birth

* 5. Mailing Address

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

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

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

* 9. Email Address (enter NA if none)

* 10. Preferred method of communication

* 11. Emergency Contact - name and relationship

* 12. Emergency Contact - phone number

* 13. Employer (enter NA if none)

* 14. Occupation (enter NA if none)

* 15. PAYMENT POLICY OF THE CENTERS FOR VULVOVAGINAL DISORDERS

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 charge card. The patient agrees to pay a $250 cancellation fee if the appointment is not cancelled or rescheduled 2 business days prior to your appointment time. If payment is rejected/returned and our attempts to resolve any outstanding balances are not successful, we reserve the right to charge the card provided to us when scheduling your appointment.

By typing your name below, you are acknowledging that you have fully read and completely understand CVVD's payment policy:

* 16. IMPORTANT POLICIES OF THE CENTERS FOR VULVOVAGINAL DISORDERS

I. Your First Appointment:
New patient appointments are approximately 1 hour and fifteen 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. Cancellation Policy:
CVVD requires two business days of notice if you need to cancel or reschedule a new patient appointment. The credit card number provided to us when scheduling the appointment is used to hold the visit and is not charged as long as two business days are given upon canceling or rescheduling. The fee for any appointment cancelled without giving two business days notice is $250.00, no exceptions. All notifications with regard to canceling and/or rescheduling appointments must be reported by phone to 202-887-0568 x101.   

**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.

III. 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.

IV. The AVERAGE cost for a new patient appointment at our Washington, DC location is $1450.00. This cost reflects the consultation, exam and all lab work performed during your visit; actual costs may vary depending on labwork/procedures performed. Our NY office charges a flat fee for new patients at a rate of $1800 for Dr. Goldstein and $1300 for Tara Ford,PA-C. Payment, in full, is required at the time of service. We accept all major credit cards, cash, and checks (from a US banking institution).

V. 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 this very extensive questionnaire. We reserve the right to cancel your appointment if the questionnaire is not submitted within the designated timeframe. Both documents can be found on our website at www.cvvd.org/contact.

VI. By typing your full name at the bottom of this form, you are acknowledging that you have read, understand, and agree to the aforementioned policies. A copy of this completed document can be provided at your request.

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