Patient Registration Step 1 of 6 16% First Name Last Name Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code PhoneEmail Marital Status Married Unmarried Other Social Security Number Sex Female Male Non-Binary Medical Questionnaire1. Do you have varicose veins or problems in your legs? Yes, my right leg Yes, my left leg Yes, both legs No 2. Have you experienced the following symptoms in your legs? (Check all that apply) Numbness Tingling Burning Itching Cramping Restless Leg Fatigue Fullness Neuropathy 3. Have you noticed any of the following on your legs? (Check all that apply) Spider Veins. Varicose (Bulging) Veins Discoloration Dryness/Eczema Hives Diminished leg hair Bruising Unexplained Bleeding Rashes Psoriasis 4. Rate the pain in your LEFT leg from 0 (no pain) to 10 (worst pain): 4. Rate the pain in your RIGHT leg from 0 (no pain) to 10 (worst pain): 5. When did do you first ever begin experiencing the above leg symptoms? 6. Please describe any activities that make your legs feel WORSE: (Check all that apply) Walking Sitting Driving Exercise Standing Work Other 7. Please describe any activities that makes your legs feel BETTER: (Check all that apply) Compression Elevation Exercise Medication Massage Heat Cold Other 8. Do you currently wear compression stockings? Yes No If yes, when did you start? 9. Have you ever experienced any of the following? (Check all that apply) Bleeding Veins Ulcerations/ Wound Cellulitis (skin infection) Blood Clots Phlebitis If Yes, please describe when this occurred, on what leg and how you were treated:10. Have you ever been previously treated for leg veins or arteries? Yes No If Yes, please describe when this occurred, on what leg and how & when you were treated:11. Have you ever been diagnosed or treated for the following. (Check all that apply) Diabetes High Blood Pressure High Cholesterol HypOthyroid HypERthyroid Lymphedema Lipedema Arterial Disease Anxiety Depression Bipolar Hepatitis B/C HIV/AIDS Cancer Congestive Heart Failure Atrial Fibrillation Clotting Disorder If yes, when were you diagnosed:Diabetes MM slash DD slash YYYY High Blood Pressure MM slash DD slash YYYY High Cholesterol MM slash DD slash YYYY HighOthyroid MM slash DD slash YYYY HighERthyroid MM slash DD slash YYYY Lymphedema MM slash DD slash YYYY Lipedema MM slash DD slash YYYY Arterial Disease MM slash DD slash YYYY Anxiety MM slash DD slash YYYY Depression MM slash DD slash YYYY Bipolar MM slash DD slash YYYY Hepatitis B/C MM slash DD slash YYYY HIV/AIDS MM slash DD slash YYYY Cancer MM slash DD slash YYYY Congestive Heart Failure MM slash DD slash YYYY Atrial Fibrillation MM slash DD slash YYYY Clotting Disorder MM slash DD slash YYYY 12. Have you recently experienced any of the following? (Check all that apply) Shortness of Breath Chest Pain Racing Heart/Palpitations Hives/Skin Changes 13. Do you currently use tobacco products? Yes No If yes, when did you start? How much do you use? If you quit, when was that? 14. What is you average alcohol intake? 15. When was your last vaccine for flu 16. When was your last vaccine for Pneumonia 17. List any allergies you have: 18. List any major medical family history: 19. Please write any additional medical diagnoses not previously listed:20. Please list any major surgeries and the years they occurred: Insurance InformationPrimarySecondaryName of Insured, if not selfCarrier NameID#Group# Employer DetailsEmployer Job Title PhoneHow did you hear about us?Name Referred By Doctor Friend/Family None Other Contact PreferencesAllow calls to home? Yes No Allow SMS (text message)? Yes No Allow postal mail? Yes No Allow voice messages? Yes No With whom may we leave a message? Allow email? Yes No Allow calls to cell? Yes No Preferred Pharmacy Consent I give consent for Medical Vein Clinic to electronically obtain my medical history. Medical Vein Clinic will use this information for reference and make sure any medications prescribed will not interact with medications I may be taking.Patient Financial Responsibility Thank you for choosing Medical Vein Clinic as your healthcare provider. We are honored by your choice and are committed to providing you with the highest quality healthcare. We ask that you read and sign this form to acknowledge your understanding of our patient financial policies. It is your responsibility to be aware of your insurance coverage, policy provisions, exclusions and limitations as well as authorization requirements. This information is furnished by your insurance carrier. We attempt to verify that your coverage is valid at the time of your visit. However, if your coverage is not in effect at the time of your visit, the financial responsibility for payment is yours. If you have had any changes in your insurance coverage - even if there is only a small change in the copayment amount or a change in the expiration date of the policy - you must notify us. Even a small discrepancy on the form can lead to a claim denial. We emphasize that as a medical care provider, our relationship is with you and not with your insurance company. It is your responsibility to know your policy. Again, we thank you for choosing Medical Vein Clinic as your healthcare provider and are here to help you! We will bill your insurance as applicable, however, you are ultimately responsible for any fees and costs not covered or paid by your insurance. Questions about non-payment should be directed to your insurance company. If you are unable to keep your scheduled appointment, we ask that you give adequate notice; so that we may open your reserved time for another patient. This helps us stay efficient in our office, but most importantly helps our patients on our “waiting list” and to our staff as well. Short Notice or “No Show” Cancellations may be charged the following fees: $25.00 for Consults / 24 hour notice required $50.00 for Ultrasound Studies / 3 days notice required $50.00 for Sclerotherapy / 3 days notice required $100.00 for Procedures / 3 days notice required Please know, each appointment cancelled that falls within this timeframe, can be reviewed and waived by management, due to extenuating circumstances not within your control. If the appointment is missed without proper notice of cancellation, the fee becomes non-refundable. This is an agreement to accept our services. We will attempt to collect unpaid balances for a period of 30 days and upon no agreement reached, the unpaid debt for our services will be transferred to our collection agency, The Phoenix Recovery Group, and will be subjected to additional fees and expenses for that process. In the case your account is forwarded to the collection agency, you may no longer be a patient at this office. INDIVIDUAL’S FINANCIAL RESPONSIBILITY I understand that I am financially responsible for my health insurance deductible, coinsurance or non-covered service. I understand that while my insurance may confirm my benefits, confirmation of benefits is not a guarantee of payment and that I am responsible for any unpaid balance. Co-payments, co-insurance, and/or deductibles are due at the time of service. If my plan requires a referral, Medical Vein Clinic will do our best to obtain with the first request; but ultimately may need your assistance with follow-up. In the event that my health plan determines a service to be “not payable”, I will be responsible for the complete charge and agree to pay the costs of all services provided (Medicare exclusions apply). If I am uninsured, I agree to pay for the medical services rendered to me at the time of service. INSURANCE AUTHORIZATION FOR ASSIGNMENT OF BENEFITS I hereby authorize and direct payment of my medical benefits to Medical Vein Clinic on my behalf for any services furnished to me by the providers. AUTHORIZATION TO RELEASE RECORDS I hereby authorize Medical Vein Clinic to release to my insurer, governmental agencies, or any other entity financially responsible for my medical care, all information, including diagnosis and the records of any treatment or examination rendered to me needed to substantiate payment for such medical services as well as information required for precertification, authorization or referral to other medical provider. MEDICARE REQUEST FOR PAYMENT I request payment of authorized Medicare benefits to me or on my behalf for any services furnished to me by or in Medical Vein Clinic. I authorize any holder of medical or other information about me to release to Medicare and its agents any information needed to determine these benefits or benefits for related services. I HAVE READ, UNDERSTAND, AND AGREE TO THE PROVISIONS OF THE PATIENT FINANCIAL RESPONSIBILITY FORM. Conset I HAVE READ, UNDERSTAND, AND AGREE TO THE PROVISIONS OF THE PATIENT FINANCIAL RESPONSIBILITY FORM. PhoneThis field is for validation purposes and should be left unchanged.