New Patient Information and Forms
New Patients
All new patients should arrive approximately 15 minutes before their appointment time. This is important to ensure that we provide you and your insurance company with accurate information in order to eliminate potential billing problems before they happen.
New Patients Need To Bring:
- Photo ID
- Current Insurance Cards
- Referral if required
- Medications and dosages
- List of past surgeries and dates
- Referring physician’s name, address and telephone number
At your first visit, all new patients will be asked to complete our New Patient Medical History Form and an Information Data Sheet. For your convenience, you can download and fill out these forms prior to your appointment.
Forms
New Patient Medical History Form - Print, complete and bring to your appointment.
Information Data Sheet - Print, complete and bring to your appointment.
Vein Questionnaire - This 4-page questionnaire aids in the proper diagnosis and treatment of your veins.
Medical Records Release Form - Use this form if we will need to obtain records from another physician or hospital for our office.
Consent for Procedure - Also available in the office.
Informed Consent for Sclerotherapy Procedure - Also available in the office.
HIPAA Privacy Practice - Print, read, sign and return at your appointment. We have this form in the office as well.
Contact the HIPAA Privacy Officer - Should you feel a need to reach a HIPAA officer, here is their contact information address.
Independent medical staff member of a hospital within St. John Health
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