Name: Date of Birth: Sex: Language: Race: Ethnicity: Home Address: City: State: Zip: Home Phone #: Marital Status: SS #:

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1 PATIENT INFORMATION: Name: Date of Birth: Sex: Language: Race: Ethnicity: Home Address: City: State: Zip: Home Phone #: Marital Status: SS #: Employer: Work #: Work Address: City: State: Zip: Cell Phone #: *: Best Contact: Home / Work / Cell / Voice Mail: Y - N Emergency Contact: Name Phone *By providing your , you agree to receive updates, news, and general information from Alliance Vein Center. We respect your right to privacy and will not share your information. INSURANCE INFORMATION: (Primary) Insurance Co.: Policy #: Group #: Name of Guarantor: Insured's Date of Birth: Insured's ID or SS: (Secondary) Insurance Co.: Policy #: Group #: Name of Guarantor: Insured's Date of Birth: Insured's ID or SS: Employer (if group policy): Employer (if group policy): ASSIGNMENT OF BENEFITS In consideration for the services rendered, I hereby irrevocably assign and transfer to Alliance Vein Center, and to any physician providing services, all rights, title and interest, to the benefits payable by any and all third party payers that are or may be liable for the services rendered, to the patient. This irrevocable assignment and transfer shall allow Alliance Vein Center, or those physicians, to pursue any such right of recovery. Even though I have made this assignment, I understand that Alliance Vein Center is a contracted provider with BCBS, Humana, Cigna & Medicare. We are not contracted with the remaining insurance providers. If we are not a contracted provider we will bill your services as an out of network provider. I understand that Alliance Vein Center, has the right to demand payment in full from me and the liability shall remain joint and several as between myself and all guarantors and third party payors, and I am responsible for payment for any charges not paid for me on my behalf Signed (Insured Person) Date RELEASE OF INFORMATION I hereby authorize Alliance Vein Center to release any information acquired in the course of my examination or treatment. Signed (Patient) Date

2 Patient Name: Age: Primary Care Doctor: Referring Physician: Cardiologist Doctor: Pharmacy: Pharmacy Phone: ( ) - Vascular History Place an x if you have any of the following: Red/purple spider veins Skin discoloration below knee Abdominal veins Bulging veins Other: Leg ulcers/open wounds Diagnosed with vein disease Years with varicose veins/spider veins Years with venous ulcers/open wounds Place an x if you have any of the following: Ache or hurt Swelling Become restless Ankle Heaviness skin changes Bleeding from veins Cramping Burning Itching Pelvic Pain Other Please check any factors that aggravate your leg discomfort: Prolonged standing Exercise Sexual Intercourse Prolonged sitting Tender to touch Other: Around/during Menstrual Cycle Pregnancy How do your symptoms affect your daily activities?

3 Please check any methods you have used to relieve your leg discomfort: discomfort Cold packs Compression hose/leg wraps Massage Exercise Pain medications Leg elevation Other: Warm soaks/heating pad Have you ever worn compression stockings? Yes If so, Stockings prescribed by: When? How long? Have you been treated for your leg veins before? Yes By whom? When? If so, By which of the following methods : Cosmetic injections Ultrasound guided injections Radiofrequency closure Laser catheter ablation Laser for spider vein Ligation: Stripping Other: Ambulatory Phlebotomy Unknown What was the outcome? What would you like to correct most about your legs? Are you currently on or have been prescribed blood thinners? Yes If yes, for how long?

4 Current Medication(s) (no need to record dosage) Allergies to medications Reaction Past Medical History Place an x if you have any of the following medical illnesses: COPD HIV or AIDS Arthritis Asthma Hole in your heart Bleeding disorder Cancer Pace Maker Blood transfusions Clot in lungs (PE) Clot in legs (DVT) Depression Diabetes Dialysis Heart attack (MI) High blood pressure High cholesterol Stroke Kidney problems Lupus Hepatitis B Hepatitis C Thyroid disease Migraines Please list any surgeries that you have had:

5 Please indicate if you have a FAMILY history of varicose or spider veins? Mother Father Maternal Grandparents Siblings Children Paternal Grandparents FAMILY history of blood clots? Yes Females Only Are you pregnant or planning on becoming pregnant soon? Yes Are you currently breastfeeding? Yes Do you have more leg discomfort on or around your menstrual cycle? Yes Number of children Number of miscarriages Occupation: Social History Do your daily activities require prolonged periods of standing/sitting? Yes If yes, what activity requires prolonged periods of standing/sitting? Do you now or have your ever used tobacco? Yes Packs per week Quit date, if applicable Average number of alcoholic beverages per week: ne