Remember to bring a valid photo I.D. (i.e. Driver s License) and your current insurance cards.

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1 Dear Patient, Welcome to our practice! You have an upcoming appointment with Dr. Charles Dietzek in one of our four office locations. Please be sure you know which office you are scheduled in. Please bring a pair of shorts to ALL office appointments to allow the doctor to exam your legs thoroughly. Drapes are available if you do not have shorts. Remember to bring a valid photo I.D. (i.e. Driver s License) and your current insurance cards. If you insurance requires a referral, please contact your primary care physician and request it as soon as possible. Please come prepared to pay your specialist co-pay at the time of service. Be advised that there will be a $10.00 administrative fee applied to your balance should we need to bill you for your co-pay for any reason. We gladly accept cash, check, Visa, or MasterCard. In order to provide you with the best care, we need to know your full medical history and any symptoms you may have, whether or not related to your chief complaint. Please fill out the attached paperwork and bring it with you to your first appointment. PLEASE DO NOT MAIL PAPERWORK TO OUR OFFICE! If you need to cancel or change your appointment, please call as soon as possible. Thank you! Vein & Vascular Institute

2 Conservative Treatment Notice IF YOU ARE BEING SEEN FOR VARICOSE VEINS, PLEASE READ THE FOLLOWING INFORMATION: Your insurance carrier may provide coverage for varicose vein treatment if you have tried conservative treatment. Conservative treatment consists of: Wearing Compression Stockings for a Minimum of 3 months. Leg Elevation Whenever Possible Weight Loss Over the Counter or Prescription Pain Medication for Symptoms. To assist us in providing care for your vein condition, please provide us with any and all attempts at conservative treatment on the attached forms.

3 Patient Name: Age DOB Visit Date Primary Care Physician: Who Referred You? Reason for today s visit: Medical History: High Blood Pressure Yes No Kidney Disease Yes No Anemia Yes No Diabetes Yes No Thyroid Disease Yes No Back Disc Disease Yes No Neuropathy Yes No Emphysema/COPD Yes No Cancer Yes No Heart Problems Yes No Asthma Yes No If Yes, what kind? Heart Attack/MI Yes No GI Ulcer Yes No Please list ALL other medical conditions: Heart Failure/CHF Yes No Aneurysm Yes No Stroke /CVA/TIA Yes No DVT/Blood Clot Yes No High Cholesterol Yes No Varicose Veins Yes No Past Surgical History: Please check all that apply Please list any other surgeries: Vein Surgery Hernia Heart Bypass Hysterectomy Heart Stent Appendix Gallbladder Family History: Cancer Yes No If yes, who? Diabetes Yes No If yes, who? Hypertension Yes No If yes, who? Heart problems Yes No If yes, who? Aneurysms Yes No If yes, who? Stroke Yes No If yes, who? Varicose Veins Yes No If yes, who? Social History: Alcohol No Yes If yes, how much Tobacco No, stopped when? Yes, how much Work Type: Provide List of All Medications you are currently taking - include all natural supplements Are you allergic to any medications? Please List. Are you allergic to any of the following? Latex Iodine/Betadine IV Dye

4 Patient Name: DOB: Review of Systems: Please check any conditions or symptoms you have currently. Cardiac: Eyes: Genitourinary: Respiratory: Angina Blurred Vision Burning when Urinating Chronic Cough Ankle Swelling Cataracts Frequent Urination Shortness of Rest Chest Pain Glaucoma Urgency to Urinate Shortness of Breath when Lying Down Chest Pain with Exertion Temporary Loss of Vision Prostate Problems Wheezing Irregular Heart Beat in One Eye. Musculoskeletal: Skin: Leg Swelling Heme/Immune: Back Pain Basal Cell Cancer Palpitations Bleeding Problems Joint Pain Cellulitis Constitutional Systems: Clotting Disorder Pain in Calf with Walking Itching Fever Hepatitis A Sciatica Melanoma Chills Hepatitis B Neurological: Rash Recent Weight Loss lbs Hepatitis C Dizziness Squamous Cell Cancer Recent Weight Gain lbs HIV/AIDS Fainting Ulcers Endocrine: Tuberculosis Headaches Excessive Thirst Gastrointestinal: Lightheadedness Excessive Urination Abdominal Pain Weakness or Numbness Ears/Nose/Throat Blood in Stool on One Side of Arm, Leg, Congestion Constipation or Face. Hearing Aid Diarrhea Psychiatric: Nose Bleeds Nausea Anxiety Sinus Problems Vomiting Depression Swallowing Problems Rehab for Drug or Alcohol Abuse Complete this section ONLY if you are here for Varicose or Spider Veins: 1. Do you experience any of the following symptoms in your legs? a. Aching Yes No f. Leg Cramps Yes No b. Heaviness Yes No g. Restless Legs Yes No c. Tiredness/Fatigue Yes No h. Throbbing Yes No d. Itching/Burning Yes No i. Other e. Swollen Ankles Yes No 2. Have your veins gotten worse in recent months? Yes No 3. Do you elevate your legs to relieve discomfort? Yes No 4. Do you take any over the counter or prescription pain medicine? Yes No If so, what kind? 5. Have you ever had your veins evaluated before? Yes No If so, when and where? 6. Have you ever had a varicose vein blood clot, or phlebitis Yes No 7. Have you ever had a deep vein thrombosis Yes No Notes: Hx reviewed with patient Initials

5 Charles Dietzek, D.O., FACOS 1101 White Horse Road Suite C Voorhees, NJ Ph: Fax: PATIENT REGISTRATION FORM Date: Home Phone: Cell Phone: Patient: Last Name First Name MI SSN# Responsible Party (if a minor): Street Address: City: State: ZIP: Sex M F Age: Date of Birth: Single Married Widowed Divorced Occupation: Work Phone: Spouse Name: Phone: Do you have Medical Insurance? No Yes Name of Primary Insurer: I.D No. Group No. Subscriber Name: Date of Birth: Relationship: Name of Secondary Insurer: I.D No. Group No. Subscriber Name: Date of Birth: Relationship: In case of an emergency, who should we contact? Name Phone Relationship Patient Release: I certify the information that I have provided is correct. I authorize the release of medical information to process insurance claims to insurance companies or their agencies (including Medicare), for purpose of filing and payment of medical claims. I authorize payment of medical benefits to the provider. I ACKNOWLEDGE THAT INTEREST OR A FEE, AT THE PROVIDER S CURRENT RATE, MAY BE CHARGED on all balances owing to the provider that are past due. I permit a copy of this release to be used in place of the original. Patient Signature: Date

6 Notice of Privacy Practice Please be advised that we are required by law to maintain the privacy of, and provide individuals with notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to this form, please ask to speak with our Office Administrator in person or by phone at our main number. In accordance with federal regulations regarding patients privacy, please read and sign the following: I, give permission to Vein & Vascular Institute to do the following: Confirm appointments by phone Leave messages on voice mail to confirm appointments Release medical information requested by another treating physician or health institution To request records as needed from other physicians and/or institutions to assist in my ongoing treatment. To be photographed before, during, and after treatments. These photographs shall be the property of Vein & Vascular Institute and may be in scientific journals, websites, and/or shown for scientific reasons. Your name and information will NOT be on these photos. The following person is authorized to receive medical information about me, the patient, in the event that I cannot be available: Contact Name: Phone: Relationship of Contact: My signature below is acknowledgement that I have received this Notice of Privacy Practice, have read the above statements, and am in complete compliance with them. Print Patient Name: Signature: Date:

7 Insurance Authorization Consent Form I understand that by signing this agreement, I am authorizing for the provision of evaluation, vascular testing and/or treatment which may include: 1. Endovenous Radiofrequency Ablation 2. Microphlebectomy 3. Sclerotherapy 4. Ultrasound-Guided Sclerotherapy I authorize direct payment of any insurance benefits to be made directly to my physician at the Vein & Vascular Institute or their billing agent. I also authorize my insurance company to furnish to the specified provider, or their agent any and all information pertaining to my insurance benefits and status of claims submitted for services rendered. I acknowledge an effort will be made to have my insurance pay for this service. In the event my insurance will not cover a service provided, I agree to be responsible for any charges or any remaining balances due after insurance has paid and the contractual obligations have been met. I consent to the release of my medical information to any insurance company for use in determining payment. This consent shall be valid for whatever period of time is reasonable, necessary, or until I revoke this consent in writing. The undersigned certifies the following: The undersigned is the patient or a duly authorized representative of the patient and as such is responsible to execute the above and accept its terms and the foregoing text has been read. Print Patient s Name Date Patient s Signature Signature of Person Authorized to Consent Relationship to Patient

8 Cancellation/No-Show Policy Please note, there will be a $50.00 charge for any Sclerotherapy or Ultrasound appointment that is missed or is not canceled within 24 hours notice of appointment time. There is also a $30.00 charge for any office visit that is missed or not canceled within 24 hours notice. Please understand, we hold these appointment times for YOU and cannot fill them without proper notice. My signature below acknowledges that I have read the above statements and are in complete agreement with them. X Patient s Signature Date

9 PLEASE TAKE A FEW MINUTES TO COMPLETE THIS SURVEY THANK YOU! HOW DID YOU HEAR ABOUT US? PLEASE CHECK THE ONE THAT BROUGHT YOU HERE Referred by Primary Care Physician: (name) Doctor recommended you to see us You requested to see us Referred by Specialist: (name) Referred by Friend: (name) Referred by VNUS Website ( Our Website Other Website (Please specify) Cherry Hill Mall Kiosk Deptford Mall Kiosk Billboard on Route73, Marlton Banner at Virtua - Evesham Road, Voorhees South Jersey Magazine SJ Magazine Girlfriendz Magazine Yellow Pages Newspaper The Courier Post The Daily Journal Phila Inquirer Gloucester County Times The Trend The Grapevine New Town Press South Jersey Sunday Sun Paper (in your town) Washington Township Times

10 Please provide us your , by doing so you are allowing us to send your special discounts and newsletters. Please note we offer a variety of cosmetic services. These services include Sclerotherapy, Botox, and Facial Fillers (Juvederm, Belotero, Radiesse, etc.) Please Print Clearly. Full Name: Address:

11 Aesthetic Interest Questionnaire Patient Name: Date: Other than the services we have already provided you, what additional services would you like to inquire about? Please check all that apply. Facial fine lines/wrinkles Leg veins (spider veins) Facial fullness/drooping Facial veins Facial contouring with fillers Length/fullness of eyelashes Botox Juvéderm Latisse Radiesse Belotero Balance Veinwave /F Care Systems Please answer the following questions on a scale of 1 to 5 by circling the appropriate number. When I look in the mirror, I believe I look younger, the same as, or older than my true age. Younger than True age Older than When I look in the mirror, I am not concerned, somewhat concerned, or very concerned about the appearance of my wrinkles. Not concerned Somewhat concerned Very concerned Do we have approval to contact you about the services you selected above? Yes No If yes, what is the best phone number to reach you? Do we have approval to send you special offers on products and services? Yes No If yes, what is your address? I m not interested in any additional services at this time.