New Patient Intake Worksheet

Personal Information
Contact Information
Emergency Contact Information
Major Medical Insurance Information
Primary Insurance

If Not Self, Provide Insured's Information:

Secondary Insurance

If Not Self, Provide Insured's Information:

Vein History
Please select the symptoms that apply to you: R = right, L= left, B = both legs
Activities of Daily Living
Conservative Therapy

Have you previously implemented any conservative therapy or Over-the-counter medication for alleviation of symptoms related to varicose veins?

Have You Had?
Mark any of the following conditions you or a family member has EVER experienced?

In this document, “I” and “my” refer to the patient, and “provider” refers to Palm Vein Center. I consent to the use or disclosure of my protected health information by Provider for the purpose of analyzing, diagnosing, or providing treatment to me, obtaining payment for my health care bills or to conduct health care operations of Provider. I understand that analysis, diagnosis or treatment of me by Provider may be conditioned upon my consent as evidenced by my signature below.

I understand that I have the right to request a restriction as to how my protected health information is used or disclosed to carry out treatment, payment or healthcare operations of the practice. Provider is not required to agree to the restrictions that I may request. However, if Provider agrees to restriction that I request, the restriction is binding on the Provider. I have the right to revoke this consent, in writing, at any time, except to the extent that the Provider has taken action in reliance on this Consent.

My “protected health information” means health information, including my demographic information, collected from me and created or received by my physician, another health care provider, a health plan, my employer or a health care clearinghouse. This protected health information relates to my past, present or future physical or mental health or condition and identifies me, or there is a reasonable basis to believe the information may identify me.

I have been provided with a copy of the Notice of Privacy Practices of the Provider and understand that I have a right that Notice’s Notice of Privacy Practices prior to signing this document. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that will occur in my treatment, payment of my bills or in the performance of health care operations of the Provider. This Notice of Privacy Practices also describes my rights and duties of the Provider with respect to my protected health information.

The Provider reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised notice of privacy practices by calling the office of the Provider and requesting a revised copy be sent in the mail or asking for one at the time of my next appointment.