Office address:

 

19415 Deerfield Avenue

Suite 213

Lansdowne, Virginia 20176

 

Phone: 703-724-9474


Fax: 571-346-1921

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.

 

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 prefer to complete the forms in the office, before your appointment, please arrive 45 minutes early, and we will provide the forms for you at that time.

 

RETURNING PATIENTS: 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.  UNFORTUNATELY, many imaging sites are getting away from printing mammograms onto sheets of film. Film is the MUCH PREFERRED way to look at a mammogram.  Important detail can be lost when a mammogram is placed on a CD, as detail is lost due to decreased resolution of the image on a computer monitor.  We are happy to have your MRI or Ultrasound/sonogram images on a CD.    Washington Radiology and the Women's Imaging Center in Reston DO print images onto film, and some, but not all, Fairfax radiology sites can print films as well.  ALL OTHE IMAGING SITES will only provide a CD. When you call to ask for your imaging, please inquire if you can get your mammograms on film, just in case something changes at any of these sites.

 

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.

 

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 to provide best service.

PRINT FOR REFERENCE
Appt Checklist_2020.pdf
Adobe Acrobat document [115.0 KB]
PLEASE PRINT AND COMPLETE
Health History Form_2020a.pdf
Adobe Acrobat document [330.1 KB]
PLEASE PRINT AND COMPLETE IF YOU ARE NEW TO LMG
Patient Information_2020.pdf
Adobe Acrobat document [319.1 KB]
PLEASE PRINT AND COMPLETE
Authorization to Disclose Health Informa[...]
Adobe Acrobat document [35.9 KB]
PLEASE PRINT AND SIGN AFTER REVIEWING PRIVACY POLICY
Privacy Signature Page_2020.pdf
Adobe Acrobat document [337.2 KB]
PRIVACY POLICY, PLEASE READ
Privacy Policy_2020.pdf
Adobe Acrobat document [337.2 KB]

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

Print Print | Sitemap
© Virginia Chiantella MD