print this page
send link to a friend
Our Philosophy    •    Our Staff    •    Contact Us    •    Home
New Patient
Information Form

 
Common Vascular
Diseases & Treatments:
Aortic Aneurysm
Peripheral(leg) Artery Disease
Carotid Artery Disease & Stroke
Varicose Veins & Venous Insufficiency
Lymphedema
Dialysis Access

Preventing Vascular Disease
 
Services We Offer
 
The Vascular Lab
 
Patient Testimonials
 
New Patient Information Form



Our Vascular Surgeon



View Brochure »

Welcome To Our Office

New Page 1
We have provided the following form for you to fill out, at your convenience. Please print it out, sign it, and bring it with you when you visit our office.

Patient's Name
Street Address
 Permanent Temporary
City and State
 Zip Code
 Home Phone #
S.S. #
 Marital Status
S M W
D SEP		 Sex
Male Female
Birth Date
(mm/dd/yyyy)		 Age
 Religion (optional)
Patient's or Parent's Employer
 Bus. Phone # Ext. #
Occupation (Indicate if Student)
 How Long Employed
Employer Street Address
City and State
 Zip Code
Drug Allergies, if any
Spouse or Parent's Name
S.S. #
 Birth Date
(mm/dd/yyyy)
Spouse or Parent's Employer
 Bus. Phone #
Occupation (Indicate if Student)
 How Long Employed
Employer's Street Address
City and State
 Zip Code
Spouse's Street Address, if Divorced or Separated
City and State
 Zip Code
 Home Phone #
PLEASE READ: All changes are due to at the time of services. I hospitalization is indicated, the patient is responsible for furnishing insurance claim forms to the office prior to hoapitalization.
Person Responsible for Payment, if Not Above
 Home Phone #
City and State
 Zip Code
Primary Insurance (Give Name of Policy Holder)
 Effective Date
 Certificate #
Group #
 Coverage Code
Other (Write in Name of Insurance Company)
 Effective Date
 Policy #
Other (Write in Name of Insurance Company)
 Effective Date
 Policy #
Medicare #
 Railroad Retirement #
 Visa Mastercard       Exp. Date
Medicaid
 Effective Date
Program #
 County #
 Case #
 Account #
Industrial
 Were you injured on the job?
Yes No  		Date of Injury
 Industrial Claim #
Accident
 Was an Automobile Involved?
Yes No  		Date of Accident
 Name of Attorney
Were X-Rays taken of this Injury or Problem?
Yes No  		If Yes, Where Were X-Rays Taken? (Hospital, etc.)
 Date X-Rays Taken
Has Any Member of your Immediate Family Been Treated by our Physician(s) Before? Include Name of Physician and Family Member.
Referred By
Street Address
City and State
 Zip Code
 Home Phone #
PROFESSIONAL SERVICES RENDERED ARE CHARGED TO THE PATIENT. NECESSARY FORMS WILL BE COMPLETED TO HELP EXPEDITE INSURANCE CARRIER PAYMENTS. HOWEVER, THE PATIENT IS RESPONSIBLE FOR ALL FEES, REGARDLESS OF INSURANCE COVERAGE. IT IS ALSO CUSTOMARY TO PAY FOR SERVICES WHEN RENDERED UNLESS OTHER ARRANGEMENTS HAVE BEEN MADE IN ADVANCE WITH OUR BOOKKEEPER.

INSURANCE AUTHORIZATION AND ASSIGNMENT
Name of Policy Holder:    HIC Number: request that payment of authorized Medicare/Other Insurance company benefits be made either to  me or on my behalf to any services furnished me by that party who accepts assignment/physician. Regulations pertaining to Medicare assignment of benefits apply.

Authorize any holder of medical or other information about me to release to the Social Security Administration and Health Care Financing Administration or its intermediaries or carriers any information needed for this or a related Medicare claim/other Insurance Company claim. I permit a copy of this authorization to be used in place of the original, and request payment of medical insurance benefits either to myself or to the party who accepts assignment. I  understand it is mandatory to notify the health care provider of any other party who may be responsible for paying for the treatment. (Section 1128B of the Social Security Act and 31 U.S.C. 381-3812 provides penalties for withholding this information.)

Copyright © 2009 South Bay Vascular Center and Vein Institute
2255 South Bascom Avenue, #200 Campbell, CA 95008
Tel : (408) 376-3626 Fax: (408) 871-2377