Patient Forms

Patient Forms 2017-08-18T00:02:33-04:00

Forms for all patients

Save time! Download new patient forms from this website, fill them out, and bring them to your first visit.

  • New Patient Intake form  In order to complete this form you will need information about your employer, insurance company, and contact numbers in case of emergency.
    Download new patient form
  • General Surgery Assessment This form gives us information about your medical history.
    Download general surgery assessment form
  • Patient Rights/Acknowledgement and Consent Form: This form covers how we will use and disclose health information about you and goes over your rights as a patient.
    Download patient rights form
  • Authorization to use/disclose health information: This form tells us who to call with information, who can receive information about your health and a brief statement about your patient rights.
    Download authorization form

Forms for specific conditions

  • Patient-informed consent for radio frequency ablation: This form gives us authorization to perform radio frequency ablation and goes over the information you should be given by your surgeon about the procedure.
    Download patient-informed consent form
  • Patient-informed consent for foam sclerotherapy: This form gives us authorization to perform foam sclerotherapy and goes over the information you should be given by your surgeon about the procedure.
    Download patient-informed consent form
  • Varicose vein daily activity form This form tells us how your current condition affects your daily activities.
    Download daily activity form
  • Breast health assessment form This form tells us how your current condition affects your daily activities.
    Download breast health assessment form

If you have any questions about these forms or how to fill them out, please call our office at 541-474-5533.