• Demographics & Health History

    FORM #1

  • Thank you for choosing Mississippi Vein Institute! Please complete the following forms prior to your upcoming appointment.

  • PATIENT INFORMATION

  • Date of Birth (MM/DD/YYYY)
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Gender*
  • Marital Status
  • Employment Status
  • Enthnicity
  • Race
  • Format: (000) 000-0000.
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  • Were you referred to us?*
  • How did you hear about us? Please check all that apply.

  • VEINS

    SYMPTOMS & ONSET
  • Please check the symptoms that you are experiencing:*
  • Which is the worse leg?*
  • Did your vein problems start:*
  • What improves your leg pain?*
  • Do you exercise:*
  • Please select any conservative measures that you have practiced:*
  • Did you wear compression hose during pregnancy?*
  • Have you ever had bleeding from a varicose vein?*
  • Have you ever had phlebitis or been treated for a blood clot?*

  • ALLERGIES
  • Are you allergic to Latex?*
  • Are you allergic to bandages?*
  • Have you had an allergic reaction to any product used on your skin?*

  • MEDICATIONS

  • HISTORY

  • Have you ever had a blood clot?*
  • Do you have a history of:*
  • Have you ever been tested for a clotting disorder?*
  • Blood Clotting Disorder:*
  • Have you EVER taken Coumadin, Plavix, Eliquis, Xarelto or any other blood thinning medications?*
  • Are you CURRENTLY taking a blood thinning medication?*
  • Are you currently prescribed hormone replacement therapy?*
  • Do you have history of joint replacement?*
  • Cardiac History:*
  • Do you have a personal history of any of the following? Check all that apply.*
  • Do you have a personal history of any of the following? Check all that apply.*
  • Could you possibly be pregnant?*
  • Are you planning a pregnancy in the future?*
  • Are you currently breastfeeding?*
  • Have you ever been diagnosed with cancer?*
  • Have you been hospitalized within the last year?*
  • Have you recently had any medical tests run or been diagnosed with a new condition in the past year?*
  • Smoking Status*
  • Do you have a FAMILY HISTORY of any of the following? Check all that apply.*
  • Which family members with venous disease? Check all that apply.
  • Are you currently under the care of a physician?*

  • CHRONIC CONDITIONS

  • Do you have bulging veins on outside of legs?*

  • FUNCTIONAL IMPAIRMENT

  • Which of the following activities are hindered by your vein symptoms (check all that apply):*

  • Signature:

     

     

    __________________________________

     

    Today's Date:

     

    __________________________________

  • Consultation Visit

  • Mississippi Vein Institute
    111 Fountains Blvd
    Madison, MS 39110
    601-707-7026

     

    Your consultation visit will consist of:

    • Duplex venous ultrasound of your legs
    • Physician Evaluation and Consultation
    • Discussion of proposed Treatment Plan
    • Consultation regarding insurance benefits
    • Discussion regarding scheduling of treatment

    This appointment typically takes approximately 2 hours from your scheduled appointment time. You will see four different medical professionals. During this visit, the plan to treat your venous disease will be explained and your insurance benefits will be reviewed. You will be able to schedule your treatment, if you would like. You will be given a folder that contains information regarding your procedure and recovery. The folder will provide pre and post op instructions, cell numbers of our staff, consents for your reivew and documentation of the benefits that we discussed with you.

    Each insurance carrier sets their own cost or "allowable fee" for this visit. An ultrasound examination is performed in conjunction with the physician evaluation. The amount due will depend on how your insurance carrier covers this visit and the specifics of your policy. Some policies charge just a co-pay, some charge the co-insurnace (usually 20-30% of allowable fees), or the visit could go toward your deductible. If your carrier assigns your financial responsibility as a co-pay or co-insurance, the patient responsibility is usually $50-400. However, if your visit goes toward your deductible the amount due will depend upon the specifics of your policy.

    Please complete the paperwork required for this visit prior to your appointment time. You can complete the forms online by clicking on this link: msvein-forms.com. We can send the forms through email if you have the ability to the print hte forms. We can also mail the forms to you. If you are unable to complete your paperwork prior to your visit, please arrive at Mississippi Vein Insititute at least 45 minutes prior to your appointment time in order to complete forms and be checked in by the time your visit should start.

    We look forwad to seeing you soon.

  • Insurance & Release

    FORM #3

  • RELEASE
    Mississippi Vein Institute will create documents and maintain records of your treatment including: history & physical examination, ultrasound results, diagnosis and treatment. Pictures will be taken and maintained as part of the record to aid in measuring the results of treatment. These pictures may be requested by your insurance company to document your disease status. Mississippi Vein Institute may use my health care information and may disclose such information to my insurance company and their agents to obtain payment for the services. Non identifying pictures will be taken to record before and after treatment results and may be used for educational and marketing purposes.


    ASSIGNMENT
    I certify that I have medical health insurance with the above listed carrier. I directly assign to Mississippi Vein Institute all insurance benefits for the services rendered. I understand that I am financially responsible for all charges not paid by insurance. I authorize my signature on all insurance submissions.

     

  • Signature:

     

     

    __________________________________

     

    Today's Date:

     

    __________________________________

  • Common Ownership Disclosure

    FORM #4

  • The owners of Mississippi Vein Institute, MS Medical Aesthetics, The Men's Clinic - Brandon and The Men’s Clinic-Madison also have a financial interest in Madison Medical Compounding Pharmacy. 

     
    By signing below, you are acknowledging we have disclosed this common financial interest to you.

  • Signature:

     

     

    __________________________________

     

    Today's Date:

     

    __________________________________

  • HIPAA Disclosure Form

    FORM #5

  • Federal legislation concerning patient privacy requires health care providers, health insurance companies, and other health related organizations to bolster their privacy practices as of April 14, 2003.


    Our Health Information Privacy Practices are available for your review. You may receive a paper copy upon your request.

     
    I acknowledge that I was informed that the privacy practices of Mississippi Vein Institute are available for my review.

  • Signature:

     

     

    __________________________________

     

    Today's Date:

     

    __________________________________

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