TML 4.01//EN" "http://www.w3.org/TR/html4/strict.dtd"> Valley Endovascular Associates

Patient Forms

Varicose/spider vein patients need to complete the following forms:

Patient History Form

Venous Health History Form

Patient Registration Form

Authorization Form for Use and Disclosure of Protected Health Information

Acknowledgement of Receipt of Notice of Privacy Practices

 

Pain management patients need to complete the following forms:

Pain Management Form

Patient Registration Form

Authorization Form for Use and Disclosure of Protected Health Information

Acknowledgement of Receipt of Notice of Privacy Practices

 

All other patients need to complete the following forms:

Patient History Form

Patient Registration Form

Authorization Form for Use and Disclosure of Protected Health Information

Acknowledgement of Receipt of Notice of Privacy Practices

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