| VARICOSE VEIN CENTER | 3475 TORRANCE BOULEVARD SUITE B-1, TORRANCE CALIFORNIA 90503 |
TEL (310) 540-1011 FAX (310) 540-1028 |
PATIENT INFORMATION |
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Name |
DOB |
SSN# |
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Home Address |
City |
State |
Zip |
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Mailing Address( if different from above ) |
City |
State |
Zip |
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Day Phone |
Eve Phone |
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Sex
Male Female |
Marital Status
Single
Married
Divorced
Widowed
Seperated |
Spouse's Name |
Healthcare Proxy Yes No |
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E-mail: @ |
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Referring Physician's Name & Address |
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EMPLOYMENT INFORMATION |
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Employed
Yes No |
Employer (Parent's employer if minor) |
Position |
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Employer's Address |
Phone |
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Spouse's Employer |
Spouse's SSN: |
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Spouse's Employer Address |
Phone |
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RESPONSIBLE PARTY INFORMATION |
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Person Responsible for Medical Expenses |
Relationship to Patient |
Phone |
|
Address |
City |
State |
Zip |
PRIMARY INSURANCE INFORMATION |
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Insurance Company |
Policy No. |
Medicare No. |
Medicade No. |
Subscriber's Name |
Subscriber's Relationship to Patient Self Spouse Patient Other |
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Address of Insurance Company |
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SECONDARY INSURANCE INFORMATION |
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Insurance Company |
Policy No. |
Medicare No. |
Medicade No. |
Subscriber's Name |
Subscriber's Relationship to Patient Self Spouse Patient Other |
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Address of Insurance Company |
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EMERGENCY INFORMATION
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Person to Contact in Case of Emergency (Other than Spouse) |
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Address |
City |
State |
Zip |
Phone |
Patient's Signature |
Date |
Spouse's Signature |
Date |
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Varicose
Vein Center © 2004
All Rights Reserved |
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