Patient Forms

The first step in finding the right treatment is locating the source of the problem. During your initial visit, the affected areas will be examined and the next steps will be determined. Depending on your case, a Doppler Duplex Ultrasound Scan might be necessary, and a separate appointment will be scheduled. This ultrasound provides a visual window, revealing the diseased, refluxing veins beneath the skin’s surface. With this diagnostic capability, the Institute can pinpoint the exact cause of varicose veins and customize a treatment plan for each individual patient – and each damaged vein. And because the problem is dealt with at its source, the treatments are quicker, more effective and less painful than traditional methods.

Also during the consultation, one of our nurses will walk through the treatment plan with you to provide an estimated number of treatments and associated costs as well as answer any questions you may have.

Patient Information Sheet

This form should be completed self-pay patients or those covered by insurance other than Blue Cross/Blue Shield or Medicare.

BCBS/Anthem

Registration form for BCBS/Anthem insured patients.

Medicare Information Sheet

Information sheet for Medicare patients.

 

History for Women

Health & Vascular history for women

History for Men

Health & Vascular history for Men

Venous Follow up

For returning patients who have not been seen in 1-2 years