Patient Form 1 Please enable JavaScript in your browser to complete this form.Patient Name *Date of Birth *Sex *MaleFemaleMailing Address *Home Phone#Mobile Phone# *Email *Race *WhiteBlackDeclined to SpecifyEmergency Contact/ Relation *Emergency Contact Phone# *Primary Care PhysicianReferred byPharmacy (please indicate cross streets) *Signature *Clear SignatureFor any insurance plan that requires the authorization of a primary care physician, it is your responsibility (as a patient or guardian) to ensure that this office receives all the necessary authorizations or referrals before treatment. Professional services are rendered and billed directly to your insurance company however you, the patient /guardian, are directly responsible for the services rendered by the physician. A health insurance policy is a contract between you (the patient or subscriber) and your insurance company. If for some reason the insurance company denies the charges, payment for services rendered will become the responsibility of the patient /guardian.I hereby authorize Palm Beach Heart and Vascular, LLC physicians/ staff/ agents to send information to insurance companies about my illness and treatments and hereby assign to Palm Beach Heart and Vascular, LLC all payments for medical services provided to me. I know that it is my obligation to know the policies of my insurance company and that I am responsible for payment if they have not met their requirements. I hereby request and voluntarily consent to routine diagnostic procedures and medical treatment deemed necessary by Paul Michael, MD and staff.Submit Patient Form 2 Please enable JavaScript in your browser to complete this form.Date of Birth *Smoking *SmokerFormer Smoker Non SmokerAlcohol *UserNon UserRecreational drug use *Non UserUserDoes anyone in your family have:Coronary Artery DiseaseStrokeAortic AneurysmPeripheral Artery DiseaseVenous DiseaseBlood Clot DisordersSudden DeathDo you have:Leg pain at restLeg cramping at restLeg weaknessLeg pain with exertionLeg cramping w/ exertionShortness of breathChest pressureChest painPalpitationsLeg pain at rest *leftrightbothLeg cramping at rest *leftrightbothLeg weakness *leftrightbothLeg pain with exertion *leftrightbothLeg cramping w/ exertion *leftrightbothShortness of breath *at restwith exertionChest pressure *at restwith exertionChest pain *at restwith exertionHave you ever had a complication with anesthesia? *YesNoAllergies *NoneIodineImaging ContrastOtherAllergiesRecent Hospitalizations Any prior testing or procedures on your legs? *NoYesAny vein treatments? *YesNoAny artery treatments? *YesNoAny prior testing or procedures on your heart? *YesNoHave you ever had any abdominal surgeries? *YesNoPlease list all other prior surgeries: Visual Text Patient Consent for Use and Disclosure of Protected Health Information I hereby give my consent for Palm Beach Heart and Vascular, LLC (PBHV) to use and disclose protected health information (PHI) about me to carry out treatment, payment, and health care operations (TPO). (The Notice of Privacy Practices provided by PBHV describes such uses and disclosures more completely.) I have the right to review the Notice of Privacy Practices prior to signing this consent. PBHV reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to the Office Manager. I have the right to request that PBHV restrict how it uses or discloses my PHI to carry out TPO. The practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement. With this consent, PBHV may call my home or other alternative location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any calls pertaining to my clinical care, including laboratory test results, among others. With this consent, PBHV may mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, PBHV may decline to provide treatment to me. The following person(s) may contact PBHV regarding my health information. You have my permission to release information to them. NameRelationNameRelationConsent for Photography, Videotaping, or Other Imaging *I GIVEI DO NOT GIVEmy consent to have photographs, videotaped images, or other images made of me. I understand and agree that these images may be used by Palm Beach Heart and Vascular, LLC for the purpose outlined below. • Teaching purposes, which includes being shown to other patients. • Advertisements by Palm Beach Heart and Vascular, LLC • Placement on practice website Signature of patient *Clear SignaturePrint Patient’s Name *Submit
