By completing this form you also acknowledge that you have been provided with a copy of Virginia Hospital Center's Privacy Notice and that you understand that the information you provide will only be used for treatment, payment and Hospital operations as described in the Notice and in accordance with applicable federal and state laws and regulations.
You will need the following information to complete this form.
(All fields are required.)
Core Services - $2,200.00 [?]
Premium Services - $3,400.00
Please specify the date you would like to participate in the Executive Health Program. Shortly thereafter, the Executive Health Manager will contact you to let you know whether or not your requested day is available. In most cases, scheduling one month in advance is preferable.
Desired appointment date (mm/dd/yyyy):
Please select any additional services you are interested in:
If you would like to schedule time with a specialist, please indicate below ($25.00 coordinating fee applies and specialist cost varies):
DermatologyGynecologyOrthopedicPhysical Medicine & RehabilitationNeurologyUrologyOther
Additional lab studies are also available as indicated by screening or exam by your Executive Health physician. Prices will vary.
Corporate Payment/Cancellation Policy:
A $250.00 registration fee is charged at the time the appointment is made. This will be applied against the final bill. The registration fee will be refunded if the appointment is cancelled at least 2 weeks (10 business days) in advance; otherwise, the fee will be forfeited in full. A valid credit card number is required to hold all appointments. Payment is expected at the time of service.
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1701 N. George Mason Drive | Arlington, VA 22205-3698 | tel 703.558.5000© 2016 Virginia Hospital Center All rights reserved