• West Medical - Vein Consultation Questionnaire

    Complete this multi-page intake questionnaire and submit it when you’re done.

  • Patient Information

  • Date of birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Gender*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Insurance Information

    West Medical Center is an out-of-network provider. This helps us verify your benefits before your visit.
  • Upload a File
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  • Are you the subscriber on this policy?
  • Subscriber date of birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • Emergency Contact and Referral

  • Format: (000) 000-0000.
  • How did you hear about us?

  • Your Vein History

    Check anything that applies and mark which leg. If it applies to both legs, choose Both.
  • Previous vein surgery or ablation - which leg?
  • Previous sclerotherapy - which leg?
  • History of DVT (blood clot in the leg) - which leg?
  • Cosmetic concerns over abnormal veins - which leg?
  • Do or did your parents or siblings have varicose veins?
  • Has anyone in your family had blood clots?
  • Have you had any blood clots in the past?
  • Do you have a history of pulmonary embolism (clot in the lung)?
  • Have you had excessive bleeding in the past?
  • Are you planning a car or plane trip longer than 4 hours in the next 6 months?
  • Are you on oral contraceptives or hormone replacement?
  • Are your abnormal veins related to pregnancy?
  • Are you currently breastfeeding?
  • Are you planning a pregnancy within 3 months?

  • Leg Symptoms

    Mark each symptom you have and which leg it affects. Leave a symptom unanswered if you don't have it.
  • Pain or aching
  • Swelling
  • Heaviness or fatigue
  • Itching
  • Restless leg sensation
  • Throbbing, tingling, or numbness
  • Bleeding from a vein
  • Cramping
  • Burning
  • Tenderness
  • Ankle swelling
  • Redness
  • Warmth
  • Skin discoloration
  • Hard lumps
  • Open sore or ulcer
  • Is the pain persistent?
  • How long have you had these symptoms?
  • When are your symptoms worst?

  • How Your Legs Affect Daily Life

    This helps document how your symptoms limit your work, home life, and activities.
  • Which activities do your leg symptoms limit? Select all that apply.
  • Have your veins worsened in recent months?
  • Do you take any medication for the pain (Advil, Motrin, or other)?
  • Do you elevate your legs to relieve discomfort?
  • Does elevating help?
  • Do you exercise?
  • Does exercise help alleviate your symptoms?

  • Your Health Background

  • Do you have or have you had any of these? Select all that apply.
  • If you have heart problems, which apply?
  • Format: (000) 000-0000.
  • Any problems with the following? Select all that apply.

  • Medications, Allergies, and Surgeries

  • Do you take blood thinners or aspirin?
  • Do you smoke?
  • Do you drink alcohol?
  • Do you regularly use recreational drugs?

  • Patient Financial Responsibility Policy

    Please read the policy below, then check each item to initial it, and sign at the bottom.
  • Thank you for choosing West Medical Center, Inc. as your healthcare provider. We are committed to building a successful physician-patient relationship with you and your family. Your clear understanding of our Patient Financial Policy is important to establishing a partnership with you in your quest for good health and well-being. If a parent, spouse or domestic partner is financially responsible for your services or is the subscriber on your insurance plan, please share this policy with them so that all have a clear understanding of our practices regarding patient/guarantor financial responsibility. By signing and initialing below you acknowledge and agree: 1. WMC is an out of network provider for my insurance carrier. Claims process under my out-of-network benefits, subject to co-insurance, deductible and in some instances co-pay. 2. Payment is due from me at the time services are rendered. WMC provides services in consideration of expected provider reimbursement. 3. My insurance company may send reimbursement checks directly to the subscriber, who may be a family member other than me. I agree to inform and share this policy with the subscriber. 4. It is my responsibility to ensure the subscriber endorses the check and that the check and explanation of benefits is remitted to WMC within 5 business days to: 17609 Ventura Blvd. Suite 106, Encino, CA 91316. 5. Should the subscriber deposit the check, I remain responsible for remittance within 5 days of deposit, and for all charges assessed by WMC. 6. Insurance Benefits: My insurance policy is a contract between me and my insurance company. WMC verifies benefits and submits claims as a courtesy. I am directly responsible to WMC for all bills, including coinsurance, deductible and co-payments. 7. Payment options: WMC offers prompt-pay discounts, hardship discounts, and payment plans. To qualify, I must keep my account in good standing by remitting all provider reimbursements paid directly to the subscriber. 8. Fees Assessed by WMC: Returned checks $35; possible cash/certified funds basis after a returned check; missed appointment $35 (48-hour notice requested, call 800-561-9000); injection cancellation $45 (24-hour notice); completion of forms $25; medical records fees as described (no charge under 5 pages, $10 clerical plus $0.25/page for 6+; actual cost for films; statutory fees for attorney requests). Refunds are not given for services already provided or opened equipment/supplies; unopened stockings may be exchanged same day only prior to opening. 9. Non-Payment on Account: Failure to remit payment in full within 5 days of receipt of insurance checks may result in delinquent status, as may missed payments on arrangements. If collection or legal action is needed, WMC may disclose relevant information to a collection agency or attorney. I am responsible for all costs of collection, including a 25% collection fee, court costs and fees, reasonable attorney fees, and interest at the legal rate. 10. Minor Patients: The parent/guardian of a minor is responsible for the minor's balance. Responsibility for treatment of minor children of divorced parents rests with both parents; WMC is not to be included in any court-ordered responsibility determinations. I certify that by initialing and signing below I have read and fully understand the above information, I am aware of my out of network benefits, and I agree to all terms contained herein.
  • Check each item to initial
  • Patient Financial Responsibility Policy — initial each term below to confirm you have read and agree to it. I am aware West Medical Center is an out-of-network provider, payment is due at time of service, and I am responsible for remitting insurance reimbursement checks and for all charges, fees and collection costs described in the policy.

  • Assignment of All Rights, Benefits and Claims

    Please read, acknowledge, and sign below.
  • This assignment is in addition to any prior assignment(s) of rights that I may have made to the medical providers, health care facilities, and other providers, or their designated associates, affiliates or assignee(s) (collectively PROVIDERS) relating to the medical care that I received or will receive from the PROVIDERS, which include, but are not limited to, West Medical Center, Inc; Mount Sinai Surgery Center, LLC; and Los Angeles Sleep Study Institute, LLC, their affiliates, assigns, and successors. To the extent I have not already done so, I hereby expressly transfer, assign, and convey all rights, causes of action, claims, titles, interests and demands of whatsoever nature relating to medical services I received from the PROVIDERS, including but not limited to: all claims for benefits under my insurance and health plan(s) for medical services; all my statutory rights; ERISA rights, statutory and otherwise; and to pursue relief of any kind including those against my insurer and health plan(s). Release of information: To the extent necessary to determine liability for payment and to obtain reimbursement, the providers may disclose portions of the patient's record, including medical records, to any person or corporation that is or may be liable for all or any portion of the provider's charge, including insurance companies, health care service plans, or workers' compensation carriers. The right to obtain copies of the actual insurance benefit plan or a summary plan description is also assigned to the providers. Financial Agreement: The undersigned agrees, whether signing as agent or as patient, that in consideration of the services rendered to the patient, he or she individually obligates himself or herself to pay the account of the providers in accordance with the regular rates and terms of the providers. Should the account be referred to an attorney for collection, the undersigned will pay reasonable attorneys' fees and all collection expenses. All delinquent accounts bear interest at the legal rate. It is the policy of the providers not to give refunds for medical services already provided, except for extraordinary circumstances at the providers' election. Assignment of Insurance Benefits: The undersigned authorizes direct payment to the providers of any insurance benefits otherwise payable to the undersigned for the medical services, at a rate not to exceed the provider's regular charges. Payment to the providers by an insurance company discharges the insurance company of its obligations under a policy to the extent of that payment. The undersigned is financially responsible for charges not covered by this assignment. Assignment of Claims and Right to Sue: The rights I assign include, but are not limited to: the right to initiate any legal proceeding or complaint including those against my insurance company and/or health plan(s); to request disclosure of governing plan documents including the summary plan description; to seek penalties including those under ERISA; to pursue all claims and causes of action under federal or state law, including antitrust laws and class action relief; to pursue or sue for breaches of fiduciary duty; to pursue equitable relief including equitable estoppel, surcharge, and reformation; and to pursue and collect attorney's fees. In asserting these rights, the PROVIDERS shall stand in my shoes such that my transfer of rights is complete and I retain no interest in them. Where any right is not transferable under applicable law, I authorize PROVIDERS to assert such matters as my representatives and collection agents.

  • Consents and Acknowledgements

    Please read each document below and check the box to acknowledge it, then sign once at the bottom for all four.
  • 1. Consent for Rendering Diagnostic Ultrasound I am in the office today for a consultation and ultrasound screening. I understand a limited or detailed ultrasound study may be done, if necessary. I authorize West Medical Center, Inc. to bill my insurance company for the services rendered. I understand that this service may be applied to my deductible/coinsurance and that I may receive a bill. This authorization and consent remain valid for the duration of treatment.
  • 2. Patient Responsibilities As a patient in our facility, you have certain responsibilities: to work with your health care team and follow all safety rules; to show respect and consideration to staff, other patients and visitors; to respect the privacy of other patients; to give complete and correct information about your health; to tell your doctor about changes in your health after you leave; to keep or timely cancel scheduled appointments; to follow the directions given after you agree to treatment; to tell your team if you wish to change decisions; to ask for clarification if you do not understand instructions; and to note that this facility does not honor Advance Directives. If you have concerns, you may contact our administrator or Medical Director, or file a complaint with the Medical Board of California at (800) 633-2322, Central Complaint Unit, 2005 Evergreen St., Ste. 1200, Sacramento, CA 95815, or contact the Office of the Medicare Beneficiary Ombudsman.
  • 3. Acknowledgement of Receipt of Notice of (HIPAA) Privacy Practice By signing this form, you acknowledge receipt of the Notice of Privacy Practices from West Medical Center, Inc., which describes how we may disclose and use your protected health information. We may change our Notice of Privacy Practices; a copy of the revised notice may be obtained by contacting us at 17609 Ventura Blvd. Suite 106, Encino, CA 91316. If you have questions about our Notice of Privacy Practices, please contact West Medical Center, Inc.
  • 4. Acknowledgement to Send/Receive Electronic Protected Health Information Please indicate whether you would like West Medical to communicate limited protected health information, such as appointment reminders, via electronic means. Email: there is some risk sending unencrypted email and information could be read by a third party; email can be forwarded and misaddressed; please refer to your email provider for HIPAA compliance; employers and online services may archive and inspect email. Text message: let us know if your phone is lost, stolen, or your number changes; while messages are sent securely they may not be received securely; your carrier may retain messages, messages on your phone may be read by others, and messages may be intercepted or read by certain apps. Some carriers charge for texts. You may withdraw consent at any time verbally or in writing.
  • Electronic Protected Health Information — I authorize West Medical to send me limited protected health information, such as appointment reminders, by the electronic means I select below.

  • Communication Preferences

    Patient Record of Disclosures / Acknowledgement to Leave a Phone Message.
  • May we contact you?
  • Cell phone messages
  • Home phone messages
  • Preferred way to reach you
  • Should be Empty: