Office addresses:

 

44055 Riverside Parkway
Suite 224
Lansdowne, Virginia 20176

 

1860 Town Center Drive,
Suite 120
Reston, VA 20190

 

Phone: 703-724-9474 or 703-858-3110


Fax: 571-346-1291 or 1-855-831-9022

Patient Forms

PLEASE MAKE SURE YOU SCROLL DOWN AND READ THIS ENTIRE SECTION.

Dr. Chiantella's practice is managed by Loudoun Medical Group. You may see this on some of the registration documents.

 

ONLY if you have been seen by Dr. Chiantella AFTER SEPT 1, 2015 are you a RETURNING PATIENT.  If you have never seen Dr. Chiantella before, OR if you have seen her but it was PRIOR TO SEPT 1, 2015, you will need to compete the below registration and health history paperwork as a NEW PATIENT, due to the office relocation  and new computer system. We apologize for any inconvenience!

 

NEW PATIENTS: Please print and complete the registration forms below. These documents can not be completed online. Please bring your completed forms to your appointment, and please arrive at least 15 minutes ahead of your appointment time. DO NOT EMAIL THESE FORMS as this is private information and your outgoing emails are not encrypted.

 

If you can not print the documents, or if you would like assistance in completing the forms, please arrive at least 30 minutes ahead of your appointment time, and you may complete them in the office. We will be glad to assist you.

 

RETURNING PATIENTS SEEN AFTER SEPT 1, 2015: Please arrive 15 minutes before your appointment time. There are no online documents for you to complete. (Yay!)

This is what you need to bring to your appointment:

--Your current insurance card and photo ID.

--A list of all your medications, including name, strength, and dose of each medicine and supplement

--Your last 3 years of breast imaging: mammograms, breast ultrasounds (sonograms), and breast MRIs. PLEASE NOTE: In order to evaluate you thoroughly, you must bring the actual IMAGES from these studies, not just the reports.  Most imaging centers require 48 hours to prepare your imaging for pickup. We are happy to have your MRI or Ultrasound/sonogram images on a CD. HOWEVER mammograms on CD can not be accurately interpreted, and you must ask the imaging center to print mammogram images onto FILM. All of the local imaging centers have been made aware that I require mammograms to be on film, and not on CD. DO NOT let the radiology staff tell you that a mammogram on CD is acceptible. Please call us from the imaging center while you are there, if the imaging center did not provide your mammograms to you on film when you go for pickup. Virginia Hospital Center, Prince William Medical Center, and Winchester Medical Center will not provide films, we have no choice but to take a CD from these locations. PLEASE call us IMMEDIATELY ahead of time if you are told you can not have your mammograms on film, so we can do what we can to keep from rescheduling your appointment once you arrive due to film problems.

 

It is a common misunderstanding that imaging centers mail actual images to the office. Unless you have relocated and your imaging was done out of the area, local imaging centers do not send images through the mail.

 

In summary, here is a film pickup check list for you to use to ask the radiology staff when you are at the imaging center to pick up your studies:  

---Are my last 3 years of breast imaging of all types in this envelope?

---Please open the envelope and check the dates with me.

---Are the mammograms on film and not on CD?

 

Again, you are coming to your visit to have a thorough evaluation. It can not be done if the information necessary for that evaluation is not provided. The appointment will need to be rescheduled if the imaging is not available at the time of the appointment. Please call us ahead of time if you have any questions at all about this, or you need assistance with what you might need to bring, or how to obtain it. We are here to help you. We hate having to reschedule appointments when a patient arives unprepared, but it must be done.

NewPacket
1017NewPtPacket.pdf
Adobe Acrobat document [4.4 MB]

We accept most types of health insurance. Please contact us for further details, or if you have any questions at all regarding your appointment.

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