Patient Forms

Please print and fill out all the forms below and bring them with you to your initial consultation.

If you have questions about any of the forms, please fill out as much as you can and we’ll clarify the rest when you arrive.

Thank You!

Vein History Questionnaire

Patient Demographics

Notice of Privacy Practice

Release of Medical Records

Physician Disclosure

Acknowledgement of Consent of Notice

Patient Acknowledgment for Follow-up Care

Consent for Use of Written Testimonial, Audio, Video and Picture

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REQUEST A FREE VEIN HEALTH SCREENING
Fill out the form below or call us at (910-798-LEGS) to schedule an appointment.
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