Skip to content

Vancouver, WA: The Centers For Vulvovaginal Disorders Patient Registration

1.Date of scheduled appointment (Required.)
2.Select the location of your scheduled appointment:
3.Full Name(Required.)
4.Date of Birth (Required.)
5.What are your pronouns?
6.Home/Mailing Address(Required.)
7.Cell Phone Number (enter NA in none)(Required.)
8.Home Phone Number (enter NA if none)(Required.)
9.Work Phone Number (enter NA if none)(Required.)
10.Email Address (enter NA if none)(Required.)
11.Preferred method of communication(Required.)
12.Emergency Contact - name and relationship(Required.)
13.Emergency Contact - phone number (Required.)
14.Employer (enter NA if none)(Required.)
15.Occupation (enter NA if none)(Required.)
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.vulvodynia.com

II. Your Providers and Care Team:
We may have visiting health care providers shadowing 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 an employee of CVVD may be present during your exam. This individual assists during the exam by handling the note-taking and box-ticking of modern-day medicine, allowing our providers to have more face-to-face time with the patient.

By typing your name below, you attest that you understand and agree to the above policies:
(Required.)
17.Required Paperwork:

The Vulvar Pain Questionnaire AND Registration form must be completed within 120 hours (5 days) of your scheduled visit; both documents can be found on our website at https://vulvodynia.com/contact
Please note the following:

-Our providers will not consult with or examine you unless you have completed these medical intake forms.
-If the paperwork is not done within 120 hours (5 days) of scheduling the appointment, a 10% surcharge will be applied to the visit fee upon check out. We also reserve the right to cancel appointments if paperwork is not received.

These policies help to ensure that all required paperwork is completed in a timely fashion which allow our providers to prepare for your appointment. Incomplete paperwork or paperwork turned in last minute places great strain on providers and staff and limits our ability to thoroughly review your very important medical history. We strive to provide patients with the best care and thank you for assistance.

*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) during 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.

The Centers for Vulvovaginal Disorders including the Washington, DC, New York, NY, Tampa, FL, and Vancouver, WA locations share an Electronic Medical Record. You are giving permission for your providers and care team to access these records as applicable to your patient care across the offices.

By typing your name below, you attest that you understand and agree to the above policies:
18.PAYMENT POLICY

Our policy is that payment is to be made at the time services are rendered. Whether or not your insurance reimburses you 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 two business days prior to your appointment time.
*We do not accept CareCredit.

Insurance and Payment Policy:
CVVD, PNW 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 Quest Diagnostics or Labcorp for processing. We will provide them with your insurance information so that they can process/bill your lab work through your insurance company. If you are uninsured or if your insurance does not cover/partially covers lab costs, the laboratory will contact you directly to collect payment. *IMPORTANT: As above, the cost of lab work is not included in the new patient or follow up fee and is separate.

Appointment Cost:
The cost for a new patient appointment with Mollie Rieff, DNP, WHNP, MPH at the Vancouver office location is $1300.00 and includes the consultation and exam. Please note, therapeutic treatments and interventions may be additional fees. 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 typing your name below, you attest that you understand and agree to the above payment policies:(Required.)
19.Cancellation Policy:

CVVD, PNW requires notice of two business days if you need to cancel or reschedule a new patient or follow-up appointment. The fee for any appointment cancelled without giving notice of two business days is $250.00.

**Please note: CVVD, PNW and Mollie Rieff, DNP, WHNP, MPH are 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.

By typing your name below, you attest that you understand and agree to the above payment policies:
20.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 our labs for specimen processing.
21.Please upload an image of your insurance card. (FRONT). This information will be used to charge your lab test. 
No file chosen
22.Please upload an image of your insurance card. (BACK)
No file chosen