Nancy Aria MD

Forms & Visit

Your Visit with Us

We look forward to seeing you at each visit. Please read the instructions if you have any questions regarding your visit.

Cash, checks and HSA cards are our preferred payment methods for office copays. We will be happy to charge cosmetic products and cosmetic procedures to your credit cards (no American Express, Carecredit or Discover). We appreciate your efforts!

We will call to remind you about your appointment 2 days prior. Please give us at least 24 hour advanced notice should you need to change or cancel your appointment.

Medical Patients

New Patients

If you are a 1st time patient with us for a medical visit. Please bring your insurance card(s) and a government issued ID (driver’s license, military ID, passport, etc).

If you have any pertinent medical document, please bring them with you to the visit.

New patient forms will be available in our office. However, you may fill out your forms at home and bring it to the visit. Please use only black ink.

Patient Information Form

Medical/HIPAA Form

Office Policy Agreement Form

Established Patients

Please let us know of any contact information or insurance information changes by filling out the following forms.

If you have not been seen in the past 3 years, you may need to fill out new patient forms prior to your visit.

Patient Information Form

Records Release Form

Cosmetic Patients

New Patients

If you have never seen us before for medical or cosmetics, we ask your fill out all the new patient forms at home or in our office.

There will be A $50 consultation fee for the first visit which WILL go towards your procedure should you decide to proceed on the same day.

Patient Information Form

HIPAA Form

Medical History Form

Office Policy Agreement Form

Established Patients

As an established patient, please let us know of any contact information changes by filling out the following form.

If you have not been seen in the past 3 years, you may need to fill out new patient forms prior to your visit.

Patient Information Form

Records Release Form

Minors

If the patient is under 18 years of age, a parent or legal guardian must accompany the patient to their appointment. If a parent/legal guardian is not able to accompany the patient, the parent/legal guardian must complete all paperwork ahead of time including the authorization for non-parent/legal guardian to accompany patient form authorizing another adult to bring their child to the appointment. In addition, the accompanying adult must be authorized on the HIPAA Form.

Minor without Parent Consent Form

Financial Agreement

Please be aware, all Form Completions (notes for employers, insurance companies, rewritten prescriptions, etc.) are subject to a $25 minimum fee.

Telemedicine Patients

Established Patients

We are currently not seeing patients in the office due to coronavirus but are available to do telemedicine visits for new and established patients who are in the Virginia, Maryland, DC area. 
Please call (703) 461-7500 for more information.

Telemedicine Consent