Healthcare Vascular Care Form

HEALTHCARE VASCULAR CARE FORM

Patient Information

Patient Name:

Date of Birth:    Gender:

Emergency Contact

Insurance Information

Medical History — Vascular Specific

  I have a known allergy to radiographic contrast

  Patient is currently taking anticoagulant or antiplatelet medication    If yes, name and dose:

  Diabetes      Hypertension      Coronary artery disease      Peripheral arterial disease (PAD)

  Chronic venous insufficiency      History of deep vein thrombosis (DVT) / pulmonary embolism      Renal disease / impaired kidney function

  Leg pain with exertion (claudication)      Resting leg pain      Non-healing wound or ulceration

  Leg swelling / edema      Skin color changes / cyanosis      Numbness or tingling

Diagnostic Studies and Procedures

Prior vascular imaging (type, date, facility):

Contrast risk factors documented:

Authorizations, Consents and Acknowledgments

Consent to Evaluation and Treatment: I authorize the physicians and clinical staff of this facility to perform evaluation, diagnostic testing, and treatments that are medically indicated for vascular disease. Such procedures may include vascular ultrasound, venous or arterial angiography, administration of intravenous contrast when necessary, endovascular interventions, sclerotherapy, and minor procedures in an outpatient setting. I understand that no guarantee has been made as to the results of any treatment.

Risks and Benefits: The common risks include bleeding, infection, vessel injury, contrast allergic reaction, worsening of ischemia, need for additional procedures, and rarely stroke, heart attack or death depending on the intervention. The expected benefits include diagnosis of vascular pathology, relief of ischemic symptoms, wound healing, and prevention of limb loss. Alternatives include conservative management, medication optimization, and referral for surgical options.

Right to Decline or Withdraw: I acknowledge I may decline all or part of the proposed care and may withdraw consent at any time prior to a procedure without affecting my future access to care.

Financial Responsibility and Assignment of Benefits: I understand I am financially responsible for charges not covered by my insurer. I authorize payment of insurance benefits to the treating facility and providers for services rendered as permitted under my insurance contract.

Release of Information: I authorize release of my medical information related to vascular care to insurers, referring providers, and the persons listed below for coordination of care and billing.

HIPAA Acknowledgment:   I acknowledge that I have received or been offered the facility's Notice of Privacy Practices describing how my health information may be used and disclosed.

Authorization to Leave Protected Health Information by Phone/Voicemail/Text:   I authorize messages to be left at the phone number(s) provided regarding appointments, test results, or billing.

Patient Statement and Certification

I certify that the information I have provided is true and complete to the best of my knowledge. I understand the nature of the proposed evaluation and treatments and have had an opportunity to ask questions which have been answered to my satisfaction. By signing below I consent to the care described above and authorize the release of medical information as indicated.

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