Patient Information. Insurance Information. Emergency Contact
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- Stephanie Boone
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1 Page 1 of 2 Name: Patient Information RVC-A1 Social Security Number: Gender:!Male!Female of birth: Mailing Address: City: State: Zip: Home phone: ( ) Work phone: ( ) Insurance Information Name of policyholder: of birth: Patient relationship to policy holder:!self!spouse!parent/guardian!other Marital Status:!Single!Married!Divorced!Separated!Widowed Emergency Contact Name: Relationship: Mailing Address: City: State: Zip: Home phone: ( ) Work phone: ( ) Financial Responsibility Agreement I/We hereby authorize Richmond Vein Center to furnish all information regarding my medical history, diagnosis and treatment of myself or my child to an insurance company regarding my claims for benefits. If however, said insurer fails to meet this obligation in whole or in part, or if I am non-insured, agree to be responsible for the fee and cost involved in the treatment of the above named patient. I/We authorize payment of medical benefits to the Richmond Vein Center and further understand that should my account have to be referred to an attorney for collection that I am responsible for all fees and costs incurred therein. I/We hereby authorize Richmond Vein Center to act on my behalf in accessing hospital records when and if needed. Patient/Guardian Signature 7702 Parham Rd. MOB III Suite 102 Richmond, VA (804)
2 Page 2 of 2 In order for us to provide better communication to your physicians regarding your care, please complete the following: 1. My primary care physician is: 2. My OB/GYN is (if applicable): 3. Who referred you to the Richmond Vein Center: Notice of Privacy Practices Acknowledgement Form Our Notice of Privacy Practices provides information about how we may use and disclose medical information about you. As provided in our notice, the terms of our notice may change. If we change our notice, you may obtain a revised copy. You will find the Notice of Privacy Practices in the white notebooks throughout the waiting room. I, (please print patient name) have been provided access to West End Surgical and Richmond Vein Center!s Notice of Privacy Practice. A copy of the Notice of Privacy Practice is available upon request. I have had an opportunity to read the Notice of Privacy Practices. I understand that I may ask questions to the Medical Practice if I do not understand any information contained in the Notice of Privacy Practices. Patient/Guardian Signature Relationship to patient if applicable Disclosure to Family Members and/or Friends I,, give the following individuals permission to access my medical records and West End Surgical and/or Richmond Vein Center permission to disclose health care information to: Name Relationship!Release information to no one 7702 Parham Rd. MOB III Suite 102 Richmond, VA (804)
3 RVC-A2 Photographic Image Consent and Release Form!! I hereby authorize Richmond Vein Center, P.C. to take photographic images of my legs and allow them to be used to help document and track the progress of my leg treatments, to be mailed to my Primary Care Physician and/or referring physician, and that they may be published in scientific journals and/or shown for scientific reasons.! I understand that these images will be the property of Richmond Vein Center, P.C. and that I will not receive any compensation (either financial or otherwise) in exchange for the use of these images. I understand that Richmond Vein Center, P.C. will remove all identifying information to the best of it"s ability when the images will be seen by those who are not related to my care and medical treatment (i.e. anyone other than Richmond Vein Center Staff, other physicians, insurers or other parties involved with the treatment of my legs).! I have had the opportunity to ask questions about the purpose for which, and about the manner in which the images will be used, and all of my questions have been answered satisfactorily. I hereby release and hold harmless Richmond Vein Center, P.C., West End Surgical Inc. and their respective physicians, officers, employees and agents from liability for any claim I have, or might ever have, in connection with the use of these photographic images.! I understand that I may refuse to sign this Authorization. If I choose not to sign, my treatment will not be affected in any way. I also understand that I may revoke this Authorization at any time except to the extent that Richmond Vein Center, P.C. has already taken action in reliance on it. I may revoke the Authorization by written notification to Debra Gould at the Richmond Vein Center, P.C. or to whomever the current practice manager of the Richmond Vein Center, P.C. is. Printed Name Witness Signature! In addition to the above stated purposes authorized, I also hereby authorize Richmond Vein Center, P.C. to use these images for marketing and educational purposes. I understand that all of the same terms, conditions, and limitations will still apply as authorized above, and that by signing here I am allowing Richmond Vein Center, P.C. to use the images of my legs for additional purposes and not changing the agreement in any other way. I also understand that Richmond Vein Center, P.C. will make every effort to insure that all identifying information be removed when using these images for the purposes of marketing and education to the public. Printed Name Witness Signature
4 Page 1 of 3 Vein Treatment Question Sheet RVC-A3 Name: : Gender:!Male!Female of Birth:! Age: Directions: Please answer the following questions, trying not to leave any blanks. Past Medical History: 1. Have you ever been in the hospital as a patient?!!!yes!!!no - if yes, for what reason? 2. Have you ever had surgery?!!!!!!yes!!!no - if yes, what type of surgery and when? 3. Have you ever had vein stripping surgery?!!!!yes!!!no - if yes, when and which leg(s)? 4. Have you ever had vein injections (sclerotherapy)?!!!yes!!!no - if yes, when, which leg(s) and where on the leg? 5. Are you presently under the care of a physician?!!!yes!!!no - if yes, for what illness or purpose? 6. Do you have any of the following? - heart disease!!!yes!!!no - lung disease!!!yes!!!no - high blood pressure!!yes!!!no - hepatitis!!!!yes!!!no - arthritis!!!!yes!!!no - leg ulcer(s)!!!!yes!!!no 7. Have you ever had a blood clot?!!!!!yes!!!no - if yes, which leg and when? 8. Have you ever had phlebitis (inflammation of a vein)?!!yes!!!no
5 Page 2 of 3 Child Rearing History: 1. Do you think that you are presently pregnant?!!!yes!!!no 2. How many times have you been pregnant?!!!!yes!!!no 3. Do you intend to have any more children?!!!!yes!!!no 4. Are you presently breast feeding?!!!!!yes!!!no 5. Have you ever miscarried?!!!!!!yes!!!no Family History: Does anyone in your family have (or used to have) varicose veins, spider veins, leg ulcers or swollen legs?!father!mother!brother(s)!sister(s)!other Personal Vein History: 1. Do experience any of the following? - Aching/pain in your legs!!yes!!!no - Heaviness!!!!Yes!!!No - Tiredness/fatigue!!!Yes!!!No - Itching/burning!!!Yes!!!No - Swollen ankles!!!yes!!!no - Leg cramps!!!yes!!!no - Restless legs!!!yes!!!no - Throbbing!!!!Yes!!!No - Other:!!!Yes!!!No 2. Do you have any problems with walking?!!!!yes!!!no - if yes, how does it affect you? 3. Do you stand much at work?!!!!!!yes!!!no - at home?!!!!!!yes!!!no 4. How does this standing affect your legs? 5. Do you smoke?!!!!!!!!yes!!!no - if yes, how many packs per day?
6 Page 3 of 3 6. Have you ever had your veins evaluated before?!!!!yes!!!no - if so, when and where? 7. Have you ever had any test(s) done on your veins?!!!yes!!!no Current Medical History: 1. Do you have any allergies (medicines, food, pollen, etc.)?!!!yes!!!no - if yes, please list them and describe your reaction? 2. Are you allergic to shrimp, shellfish or any form of iodine, IVP dye?!yes!!no 3. Are you presently taking any medication(s) including prescription and/or nonprescription (over-the-counter) medicines (aspirin, vitamins)?!!yes!!!no - Please list them: 4. Do you take blood thinning medications?!!!!yes!!!no - if yes, Please list name(s)? 5. Are you taking hormones or birth control pills?!!!!yes!!!no - if yes, Please list name(s)?
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