Virginia Medical Weight Loss | Patient Information

Patient Name*

First Last

Birthdate*

Age*

Social Security Number*

Marital Status*

Address

Street Address Address Line 2 City State ZIP Code

Home Phone*

Work Phone

Email Address

Primary Care Physician (Name)

Emergency Contact (Name)*

Emergency Contact (Phone)*

How did you hear about us?

Patient Policy Payment is due in full at the time of service ($165 initial - $55 followup). We do not process insurance claims out of the office and therefore insurance cards are not accepted at the time of your visit. We do accept cash, personal checks, or credit card (Mastercard / Visa.) There is a $40 charge for all returned checks. A receipt will be given (if requested) at the time of payment so that you can submit it to your insurance company on your own to request reimbursement. Signature & Date:

I understand the above payment policy and agree to it.

Card Type

If you wish to pay your account with a credit card, please provide the information here.

Credit Card Number

Expiration Month

Expiration Year

Records Release I hereby authorize Dr. Ronald H Johnson to release any of my medical information to any referring doctor as necessary, to my insurance company as necessary, and to the responsible party as needed and as requested. Signature & Date:

Please print, sign, and bring with you on your visit to our office.