Vascular Surgery Patient Registration Form

Patient Information

• Full Name: _________________________ Date: //___
• Date of Birth: //___ Age: ____ Gender: □ M □ F □ Other
• SSN: --____
• Address: ________________________________________________
• Phone: (Home) ____________ (Cell) ____________ (Work) ____________
• Email: ________________________________________________
• Emergency Contact: _________________ Phone: ________________

Insurance Information

• Primary Insurance: _________________ ID#: ________________
• Secondary Insurance: _______________ ID#: ________________
• Policy Holder Name: ________________ DOB: //___

Vascular History

Please check all that apply: □ Deep Vein Thrombosis (DVT) □ Peripheral Arterial Disease (PAD) □ Varicose Veins □ Aneurysm □ Carotid Artery Disease □ Blood Clotting Disorders

Risk Factors

□ Smoking History: □ Current □ Former □ Never □ Diabetes □ Hypertension □ High Cholesterol □ Family History of Vascular Disease

Current Medications

Allergies

• Medication Allergies: ____________________________________
• Contrast Dye Allergy: □ Yes □ No
• Latex Allergy: □ Yes □ No

Previous Vascular Procedures

Procedure: _________________ Date: //___ Procedure: _________________ Date: //___

Authorization

I certify that the above information is accurate and complete:

Signature: _________________________ Date: //___