Patient Registration Form

All Areas Must Be Filled Out Completely

Today’s Date *

Patient’s Name *

DOB *

Age

Marital Status

Referring MD *

Reason for the visit: *

Medical History

Were YOU ever diagnosed with any of the following? Please check if yes:

High Blood Pressure

Bleeding Disorders

Pulmonary Embolism

Neuropathy

High Cholesterol

Hypothyroidism

Heart Attack

Aneurysm

Arrhythmias

Seizure

End Stage Renal Disease

Kidney Disease

Heart Murmur

Asthma

Varicose Veins

Sleep Apnea

Diabetes

Depression

Congestive Heart Failure

Tuberculosis

Anxiety

Heart Disease

Carotid Artery Disease

Hepatitis

HIV / AIDS

Hernia

Peripheral Vascular Disease

Deep Vein Thrombosis

Stroke

Angina

Peripheral Arterial

Anesthesia Complication

Liver Disease

COPD

Cancer:

other:

Current Medications:

Please list current medications, dosages, and frequency. Include non-prescription, occasionally used medication (i.e. Tylenol, Advil, ect.), and vitamins. If none please put N/A.

Medication Names : *

Dosage and Frequency : *

Medication Allergies:

Please list any allergies to medication, latex, anesthesia, or dye and reactions you have to these medications. If none please put N/A.

Medication Names : *

Reaction to Medication : *

Surgical/Hospitalization History:

Please List any surgical procedures or hospital stays along with the month/year. If none please put N/A.

Month/Year	Reason/Procedure

Procedure/Treatment History:

Please indicate if you have had any of the following. If yes, provide the date, facility, and explanation on the line provided. Please select one for each.

Family History:

Please check below if any family member(s) has/had any of the following conditions, and indicate the relationship.

Social History *:

Please select one for each.

Review of Systems *:

Please indicate below if you are CURRENTLY experiencing any of the following symptoms. If yes, explain the circulation and how long you have experienced the symptom. Please select one for each.

Patient Information

Please Give Complete Legal Name

Last Name *

First Name *

Maiden Name

Address *

City *

State *

Zip *

SS#

Date of Birth *

Home Phone

Cell Phone *

Marital Status: *

Race

Employer

Work Number

E-Mail Address *

Primary Care Physician *

Referring Physician

Preferred Pharmacy *

City That Your Pharmacy is Located in *

Pharmacy Phone Number *

Below Are Questions Concerning The Primary Insurance Holder (If Different From Patient)

Last Name

First Name

Address

City

State

Zip

SS#

Date of Birth

Home/Cell Phone

Emergency Contact

Last Name *

First Name *

Relationship *

Home Phone

Cell Phone *

Work Phone

I hereby authorize the release of any confidential medical information, including information related to psychiatric care, drug, and alcohol abuse and HIV/AIDS, necessary to process insurance claims or any other medical information that is required for any health care related utilization review of quality assurance activities or to any healthcare professional requiring this information in order to treat me.

I hereby assign and authorize payment to North Atlanta Vascular Clinic PC for all medical and/or surgical benefits, including major medical policies, to which I am entitles under any insurance policy or policies, any self-insurance program, or any other type of benefit plan. I understand and acknowledge that this assignment of benefits does not relieve me of any financial responsibility for all medical fees and charges incurred by me or anyone on my behalf. I hereby accept such responsibility, including, but not limited to, payment of those fees and charges not directly reimbursed to North Atlanta Vascular Clinic PC by any insurance policy, self-insurance program or other benefit plan.

This Authorization shall remain in effect until revoked by me in writing. A photocopy of this authorization shall be considered as effective and valid as the original. I understand that I have the right to receive a copy of this authorization.

Signature *

Date *

Alternative Contact Authorization

North Atlanta Vascular Clinic & Vein Center is a multi-physician practice. This means on some occasions if your physician is called away to an emergency, you may be seen by another physician that day or rescheduled to another day. Unfortunately due to our patient care policy we cannot allow the transfer of permanent care between physicians. Thank you for your understanding and continued support of our practice.

Patient Name *

Date *

Patient Signature *

2685 Peachtree Pkwy, Suite 320, Suwanee, GA 30024

4040 Old Milton Parkway, Suite 200, Alpharetta, GA 30005

1080 Sanders Road, Suite 200, Cumming, GA 30041

771 Old Norcross Road, Suite 300, Lawrenceville, GA 30046

Phone: 770-771-5260 Fax: 770-771-5269

Financial Policy

We hope to make your visits in our office as thorough and pleasant as possible. We also want you to have a full understanding of our financial policies and expectations for payment and services. Please carefully review and sign our financial policy, and let us know of any questions you may have.

The primary and final relationship is between the Physician and you (the Patient). Our contract is with you only. We will not compromise your medical care to satisfy ANY insurance company. Please bear in mind that insurance is meant to help defray the cost of medical care and is NOT intended to dictate your treatment.

Payment is due in full at the time services are rendered. This includes deductibles, co-payments, co-insurances and non-covered services.

As a courtesy, we are happy to assist you in the filing of most insurance claims and completing insurance forms and insurance precertification. You will be responsible for any and all balances not covered by your insurance. If your insurance has not paid their portion within 60 days of being property billed, the entire balance will be your responsibility. The ULTIMATE RESPONSIBILITY for the filing and processing of claims to satisfy your insurance carrier REMAINS WITH YOU. If you are unsure of any specific requirements of your insurance, PLEASE ASK THEM. As the insured client, you are in the best position to follow up with your insurance carrier to ensure payment is being processed. It is your responsibility to inform us in cases of any change of your insurance or policy type, failure to do so results in you being responsible for the amount.

You will receive a monthly statement requesting payment of any unpaid balance. If your account becomes past due, please contact our office to discuss payment arrangements and avoid further collection efforts. We are committed to being sensitive to patient financial difficulties, but are unable to assist if you do not contact us to discuss your account. Nonpayment will result in your account turned into a collection agency and discharge from the practice. You will be responsible for collection charges borne by the collection agency on top of the amount due from North Atlanta Vascular Clinic PC.

There is a fee (currently $35) for any checks returned by the bank. Appointments not cancelled within 24 hours notice may result in charges for time reserved. This will be billed directly to you and will involve a standard fee of $40.

We are here to serve your health needs and will work hard on your behalf, to contain fees and other charges while delivering quality health care to you.

I have read and understood the above policies. I understand that I may receive a copy of this form upon request.

Patient Name*

Date*

Signature of Patient or Responsible Party*

Patient Consent For

Photography/Videotaping/Other Imaging For Treatment, Education, Marketing Or Media Purposes

Patient’s Name *

DOB *

Beginning (Date) the above named patient hereby grants permission to North Atlanta Vascular Clinic and Vein Center to interview, photograph, create digital images (e.g., CD, DVD,) and/or videotape him/her; and/or to supervise any others employed by the practice who may provide do the interview, photography, and/or videotaping during my care.

The patient or the patient's representative must read and initial the following statements (Mark through any terms not agreeable to patient):

I understand that the photographs/digital images/recordings may be published for any purpose and in any form. Examples of such uses may include (but not be limited to): to track progress during treatment, education and training of health-care providers or the general public and public relations or marketing efforts of the practice.

Initials:

I understand that with this consent I hereby give North Atlanta Vascular Clinic and Vein Center permission to use, reproduce, publish, republish, distribute copyright and publicly display my photograph.

Initials:

I understand that if I do agree, these images/recordings may be used by North Atlanta Vascular Clinic and Vein Center in patient education materials or in practice related publications or electronic media available to the public for an indefinite time.

Initials:

I understand that I will not be compensated for these photographs/images/recordings whether or not they are published.

Initials:

I understand that I am free to refuse to allow my photograph to be used by North Atlanta Vascular Clinic and Vein Center and that my health care and the payment for my health care will not be affected if I do not sign this form.

Initials:

I understand that I may see and obtain a copy of the images/recordings described on this form, if I ask for it, and that I get a copy of this form after I sign it.

Initials:

I understand that information used or disclosed based on this consent in publications or in electronic media available to the public, such as our website, may not be protected by federal or state law protecting confidentiality.

Initials:

Right to Revoke Consent

I understand that I may revoke this consent at any time by notifying North Atlanta Vascular Clinic and Vein Center in writing, but if I do it won't have any effect on any actions North Atlanta Vascular Clinic and Vein Center took under this consent and before they received the revocation.

Please note that all images/recordings are part of the medical record and must be maintained in the patient record in keeping with state or federal law regardless of the revocation of this consent.

Initials:

Please indicate your agreement to the above by signing below.

Signature of Patient/Guardian *

Date *

Print Name *

Patient Registration Form

All Areas Must Be Filled Out Completely

Medical History

Current Medications:

Medication Allergies:

Surgical/Hospitalization History:

Procedure/Treatment History:

Family History:

Social History *:

Review of Systems *:

Patient Information

Below Are Questions Concerning The Primary Insurance Holder (If Different From Patient)

Emergency Contact

Alternative Contact Authorization

Financial Policy

Patient Consent For

Right to Revoke Consent

Authorization for Release of Medical Information

FOR OFFICE USE ONLY

NOTE: Medical Records are Faxed in Cases of Medical Necessity Only.