New Patient Registration

PREVENTATIVE SCREENING
Have you had a colonoscopy or other form of colon cancer screening? (INCLUDE APPROX DATE)*
Have you had exposure to second hand smoke for >20 years?*
IF OVER 60: Have you had the Shingles Vaccine? (Zostavax)
IF OVER 65: Have you had the Pneumonia Vaccine? (Pneumovax)
Last Tetanus shot? (INCLUDE APPROX DATE)*
Are you interested in a Flu shot this Flu season?*
WOMEN: When was your last Pap Smear? Anything Abnormal? (INCLUDE APPROX DATE)
WOMEN: When was your last mammogram? Anything Abnormal? (INCLUDE APPROX DATE)
WOMEN: When was your last bone density osteoporosis screening? Anything Abnormal? (INCLUDE APPROX DATE)
MEN: When was your lastProstate Cancer Screening? Anything Abnormal? (INCLUDE APPROX DATE)

FINANCIAL POLICY
The following is a statement of our Financial Policy. We require you to read and sign in agreement with this policy prior to any treatment. We do not take insurance, but you can submit your superbills to your insurance company. We will provide codes for you to submit in a superbill if desired, but we cannot guarantee that any portion of fees will be covered by any particular plan. Neither Dr. Fred Grover nor any Revolutionary MD staff member can engage in phone calls or letters with any and all insurance companies.
- We accept cash, checks, and all major credit cards
- The fee for a returned check is $50
- Patients are responsible for payment after completing patient visit on day of service
- Appointments cancelled less than 24 hours prior to a scheduled time may be subject to a $50 cancellation fee.
I have read the Revolutionary MD policies presented above. I understand and agree to the Revolutionary MD policies:*

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We welcome you to the Revolutionary MD Practice by Dr. Fred Grover!
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ADVANCED WELLNESS PROGRAM WITH DR. GROVER: Includes up to 10 visits a year, ongoing medical care, hormone-balancing, medication management, discounts on skin care services, discounts on supplements.
BIO-IDENTICAL HORMONE BALANCING: Dr. Grover is an expert in hormone replacement therapy and is board-certified in anti-aging medicine. Hormone pellet therapy is now available and lasts for 4-6 months.
THYROID/ADRENAL/GROWTH HORMONE BALANCING: Dr. Grover specializes in the treatment of hypothyroidism, subclinical hypothyroidism, adrenal fatigue, and growth hormone deficiency.
BOTOX and/or FILLER: Dr. Grover has been an advanced injector since 2005.
VIVACE RADIO-FREQUENCY MICRO-NEEDLING: Treats fine-lines, wrinkles, cellulite, sagging skin, and collagen-loss on the face, neck, hands, and body.
GENETIC TESTING: Dr. Grover offers Telomere testing to determine how well you are aging. He also uses additional tests to determine cancer risks, detox/methylation impairment (MTHF), optimal diet based on gene-type, and other health conditions to optimize wellness.
WEIGHT LOSS PROGRAM: Dr. Grover offers the latest FDA-approved weight-loss therapy. Curve hunger, regulate your blood-sugar, and lose approximately 15lbs in just 3 months with Semaglutide alone. Additional weight loss is expected if lifestyle changes are also made.
IV SUITE: NAD+, Glutathione, Methylene Blue, Vitamin C, VitAmino, Curcumin, etc.

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