New Patient Packet

HISTORY OF PRESENT ILLNESS

Patient Name:

Patient Birth Date:

Today's Date:

Reason for today’s visit:

Primary Care Physician: Dr.

Phone Number:

Referring Physician: Dr.

Phone Number:

Cardiologist Physician: Dr.

Phone Number:

Nephrology Physician: Dr.

Phone Number:

Endocrinology Physician: Dr.

Phone Number:

Podiatry Physician: Dr.

Phone Number:

Have you had any Labs, Ultrasounds, X-rays, MRI’s, CT’s, etc.?

Yes No

If yes, explain which:

When

In case of a surgical emergency, are you willing to receive blood or blood products?

Yes No

Are you pregnant, nursing or planning a pregnancy in the near future?

Yes No

PAST MEDICAL HISTORY

Please provide dates and results for the following:

Date of most recent cardiac stress test

Date of most recent heart catheterization

Stents?

YES NO

Do you smoke?

YES NO

Cigarettes

Vape

Marijuana

If yes, Qty/ Frequency:

If no, Date Quit

Allergies:

Other:

Do you have problems/ complications with anesthesia?

YES NO

Have you had any Falls in the past year?

YES NO

Two or more Falls with injury?

YES NO

MEDICATIONS

Add Medication

Have you had any of the following?

Seizure Disorder?

Thyroid Disease

Pulmonary Disease

Asthma

COPD

Emphysema

Stroke

TIA (mini stroke)

Gl Disease

Ulcers

Gallstones

GERD

Diverticulitis

Crohn's

Diabetes

Insulin dependent

Non-insulin

Controlled by diet

Kidney Disease

Dialysis

Yes No

Blood Disorder

Liver Disease

Hepatitis

Cirrhosis

Cancer

Type:

Vascular Disease

Heart Disease

AFIB

Hypertension

CHF

FAMILY HISTORY

Please check the boxes pertaining to your family history.

Living

Father

Mother

Brothers

Sisters

Deceased Cause/death

Father

Mother

Brothers

Sisters

Cause of Death:

Age of death

Father

Mother

Brothers

Sisters

Age of Death:

VENOUS HISTORY

Spider Veins

Varicose Veins

Check box in front of ALL that apply:

SYMPTOMS:

Aches

Swelling

Heavy/full feeling

Cramping

Itch

Burning

Leg Restlessness

Pelvic Symptoms

Ulceration

WORSE WHEN:

Standing

Pre-menstrual

Worsening of symptoms with pregnancy

Sitting

Night time

Walking/exercise

Other

Worsening of symptoms with pregnancy; Date of last pregnancy:

CONSERVATIVE THERAPY:

Leg Elevation

Exercise

Heat/Ice

Elastic compression garment use; Attempted more than 3-6 months.

Compression garment use Helpful

Compression garment use Failure

If Compression garment use Failure; Reason:

Vein Treatments/Procedures

Venaseal

Ablations lasers

Varithena sclero

COMMENTS:

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Patient signature:

Date

CANCELLATION POLICY

OFFICE VISITS, VASCULAR LAB TESTS, SURGICAL PROCEDURES

To better serve all of our patients, it is extremely important that when you schedule your visits, tests, or surgical procedures that you have thoroughly checked your personal calendar to make sure the time is ideal for you. Cancelling and rescheduling causes other patients to wait longer and delay treatment times.

UNPLANNED CANCELLATIONS AND NO SHOW POLICY

Each Office visit will be rescheduled one time as a courtesy. After that time, a $50 fee will be charged to your personal account and not billed to insurance for every cancellation less than 24 hours of the scheduled appointment or a No Show appointment.
Each Vascular lab test will be rescheduled one time as a courtesy. After that time, a $150 fee will be charged to your personal account and not billed to insurance for every cancellation less than 24 hours of the scheduled appointment or a No Show appointment.
Each New Patient Office visit will be rescheduled one time as a courtesy. A No Show Fee of $100 will be charged to your personal account and not billed to insurance for every cancellation less than 24 hours of the scheduled appointment or a No Show appointment.
Surgical procedures in the office must be cancelled or rescheduled 48 hours in advance. Failure to do so will result in a $200 fee charged to your personal account and not billed to insurance.
Surgical procedures in the Hospital cannot be rescheduled. If you must cancel, it will need to be within 72 hours to release the time to other hospital patients. Failure to do so, will result in a $250 fee charged to your personal account and not billed to insurance.
Vein/MSA procedures in the office must be canceled or rescheduled 48 hours in advance. Failure to do so will result in a $100 fee charged to your personal account and not billed to insurance
After 3 cancellations with late notices or 3 No Show appointments, the patient will be required to speak with the Practice Administrator before rescheduling.

Thank you, Space Coast Vascular Staff

I have read, understand and agree to the cancellation, no show and financial policies of Space Coast Vascular.

Patient Name:

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature:

Date

Witness:

Date

New Patient Registration

Patient Information

Patient Name

First, MI, Last

DOB

SS#

Marital Status

MALE FEMALE

Address

Home Phone

Cell Phone

Work Phone

Employer

Occupation

Name of Spouse

Address:

Check if same as patient’s address

Race

American Indian or Alaska Native Native Hawaiian Other Pacific Islander Asian Black or African American Prefer not to answer White

Ethnicity

Hispanic/Latino Non-Hispanic/Latino Prefer not to answer

Preferred Language

English Spanish French Indian (includes Hindu & Tamil) Other

Preferred Pharmacy

Location

Insurance Information

Primary Insurance Co

Policy #:

Policy holder information, if not same as patient:

Name

DOB

SS#

Secondary Insurance Co

Policy #:

Policy holder information, if not same as patient:

Name

DOB

SS#

HIPAA Release

Patient Name

First, MI, Last

Emergency Contact:

Name

Relationship

Phone #

Do you have a Living Will?

Yes No

Do you have an Advance Directive?

Yes No

If you answered yes to either, please provide us a copy.

I authorize Medical Associates of Brevard LLC to discuss my healthcare information with the below:

Add Name

Preferred appointment reminder notification:

Home Phone Mail With the person(s) authorized above Cell E-Mail Cell Text Work phone None

Preferred medical information notification: I authorize Medical Associates of Brevard LLC to leave a detailed message which may contain personal health information via:

Home Phone Mail With the person(s) authorized above Cell E-Mail Cell Text Work phone None

Note that authorization to contact via phone includes authorization for us to leave a message on your voicemail or answering machine.

Your HIPAA contact information will be recorded as you have indicated here. You will be asked to electronically sign to confirm this information.

Annual Updated Patient Registration

NOTICE OF MEDICAL / FINANCIAL RECORDS REQUEST FEES ACKNOWLEDGEMENT

Please be advised of our policies and fee schedule for providing copies of medical records or financial statements of account. Fees are calculated in compliance with Florida Statutes, Title XXIX, Chapter 395, § 3025] and federal HIPAA regulations.

TYPE & FEE:

Paper copies (to patient/individual) $1.00 per page for the first 25 pages, and $0.25 for each additional page

Paper copies (to third parties/attorneys) $1.00 per page (max allowable rate)

Records to another healthcare provider for continuation of care No Charge

Medical Record Affidavits $10.00 per affidavit completed

Forms (FMLA, Disability, etc.) $25.00 for one page; $35.00 for multiple pages

Postage/Shipping cost will vary depending on weight and postage at time of shipping

TERMS:

**payment is required in full before records will be released. We accept: Cash, credit card and debit cards.

**Requests are typically processed within 10-15 business days of receiving a signed authorization and payment.

**These fees will also have an additional charge for the actual cost of postage for mailing records.

ACKNOWLEDGEMENT:

By signing this form, | acknowledge that | have been informed of this fee schedule and agree to be financially responsible for all applicable charges.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Patient

Date

Your information will be encrypted.