OPTIMA VEIN CARE

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Name: __________________________________ DOB:________________ Age: ____YO Sex: F M

Height: _______ Weight: _______lbs SS#: _____________________ Married Single Divorced Widow Mailing Address: __________________________ Apt/Unit: ______ City: ______________ State: _______ Zip: ___________

Check Contact preference: Cell __________________ Home __________________ Work __________________

Employer __________________________________ Email Address: _________________________________

Job Title ___________________________________

Emergency Contact

Name __________________________ Relationship to you ______________ Phone: ______________________

I DO NOT GIVE anyone consent to coordinate my appointments and to have access to my health information.

I GIVE the following person consent to coordinate my appointments and have access to my health information.

Check, if the same as emergency contact

Name __________________________ Relationship to you ______________ Phone: ______________________

Race:

American Indian/Alaska Native Asian Black or African American Black Hispanic or Latino

Native Hawaiian /Pacific Islander White White Hispanic or Latino Other: ________________

Hispanic/Latino Non Hispanic

Language: Spoken _______________ Read _________________ How did you hear about us? ______________

PHYSICIAN INFORMATION May we send a progress report? YES / NO

Primary Care Physician: __________________________ Physical Therapist: ____________________________________

Cardiologist/Vascular: ___________________________ Orthopedist/Podiatrist: _________________________________

Dermatologist/Aesthetician: ________________________ Other: _________________________________________

Pharmacy ________________________ Address ______________________________ P# ________________________

INSURANCE INFORMATION

Primary: _____________________

Policy #: _____________________

Group #: ____________________

Policy holder: ________________

Relationship to policy holder:

Self Spouse Child Other

Secondary: __________________

Policy #: _____________________

Group #: ____________________

Policyholder:_________________

Relationship to policy holder:

Self Spouse Child Other

By initialing, I have read and was

offered a copy of:

_____ FINANCIAL AGREEMENT Initial _____ NOTICE OF PRIVACY PRACTICE Initial

By initialing, I give consent for the following: ____ Contact me through email ____ Establish a patient portal account

OPTIMA VEIN CARE

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Briefly explain the reason for your visit today: _______________________________________________________

Do your legs/ ankle currently:

□ Hurt/Ache/Throb/Burn □ Swelling □ Become tired/ heavy □ Cramp □ Restless legs Pain scale 1-10: ______ □ Itch □ Other:________________________

Please check if you have ever had:

□ Visible veins □ Bleeding from leg veins □ Calf Pain wile walking/standing

□ Leg swelling □ Transfusion for leg bleeding □ Blood clots in legs

□ Skin discoloration below your knee □ Ankle sores/ ulcerations □ Other: _______________

How do your symptoms negatively affect your daily activities? (work/daily functional living)

Example 1:__________________________________________________________________________________

Example 2:__________________________________________________________________________________

Other: _____________________________________________________________________________________

Are you on your feet for long periods? Y N Reason? ____________________________________________

Evolution began: ____________ years/months ago

Please check any methods you have used to relieve your leg discomfort:

□ Leg Elevation □ Exercise/ Walking

□ Aspirin/ Tylenol/ Ibuprofen/ Other: ___________ Taking for how long: ______ years/months

□ Support Stockings: Knee High Thigh high Panty Hose For how long? ______ years/months

Prescribed by Physician: _______________________________ Date Prescribed: ______________________

Results from wearing compression stocking: ____________________________________________

(Insurance Coverage Requirements-please note your insurance company requires you to have tried support stockings for

a minimum of 3 months in order to approve treatment)

PREVIOUS VENOUS TREATMENTS □ No history of vein treatments

□ Surgery/ Stripping □ EVLT/ Laser □ Sclerotherapy/ Injections

□ Radiofrequency/ VNUS □ Laser for spider Veins □ Cosmetic Injections

□ Phlebectomy/TriVex □ Other ____________________________

Treated by? ___________________________________________ When? ______________________________

Results from treatment: _________________________________

OPTIMA VEIN CARE

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REVIEW OF SYSTEM:

Const. (Health in General) ❑ No Problems

Lack of energy, unexplained weight gain or weight loss, loss of appetite, fever, night sweats, pain in jaws when eating, scalp tenderness, prior diagnosis of cancer Other: __________________________________

Ears, Nose, Mouth & Throat ❑ No Problems

Difficulty with hearing, sinus problems, runny nose, post-nasal drip, ringing in ears, mouth sores, loose teeth, ear pain, nosebleeds, sore throat, facial pain or numbness. Other: ________________________________________

C-V (Heart & Blood Vessels) ❑ No Problems

Irregular heartbeat, racing heart, chest pains, swelling of feet or legs, pain in legs with walking. Other: _______________________________________

Resp. (Lungs & Breathing) ❑ No Problems

Shortness of breath, night sweats, prolonged cough, wheezing, sputum production, prior tuberculosis, pleurisy, oxygen at home, coughing up blood, abnormal chest x-ray. Other: ______________________________________

GI (Stomach & Intestines) ❑ No Problems

Heartburn, constipation, intolerance to certain foods, diarrhea, abdominal pain, difficulty swallowing, nausea, vomiting, blood in stools, unexplained change in bowel habits, incontinence. Other: ______________________________________

GU (Kidney & Bladder) ❑ No Problems

Painful urination, frequent urination, urgency, prostate problems, bladder problems, impotence. Other: ______________________________________

MS (Muscles, Bones, Joints) ❑ No Problems

Joint pain, aching muscles, shoulder pain, swelling of joints, joint deformities, back pain. Other: _______________________________________

Integ. (Skin, Hair & Breast) ❑ No Problems

Persistent rash, itching, new skin lesion, change in existing skin lesion, hair loss or increase, breast changes. Other: ____________________________

Neurologic (Brain & Nerves) ❑ No Problems

Frequent headaches, double vision, weakness, change in sensation, problems with walking or balance, dizziness, tremor, loss of consciousness, uncontrolled motions, episodes of visual loss. Other: _______________________________________

Psychiatric (Mood & Thinking) ❑ No Problems

Insomnia, irritability, depression, anxiety, recurrent bad thoughts, mood swings, hallucinations, compulsions. Other: _______________________

Endocrinologic (Glands) ❑ No Problems

Intolerance to heat or cold, menstrual irregularities, frequent hunger/urination/thirst, changes in sex drive. Other: __________________________

Hematologic (Blood/Lymph) ❑ No Problems

Easy bleeding, easy bruising, anemia, abnormal blood tests, leukemia, unexplained swollen areas. Other: _______________________________________

Allergic/Immunologic ❑ No Problems

Seasonal allergies, hay fever symptoms, itching, frequent infections, exposure to HIV.

Other:________________________________________

PAST MEDICAL HISTORY: □ No history of any medical problems

□ Seasonal/Environmental allergies

□ Arthritis

□ Varicose Veins

□ Peripheral arterial disease

□ Clotting disorder

□ Cerebrovascular accident

□ Obesity

□ Seizures

□ Hypertension

□ DVT

□ Angina

□ Heart Attack

□ Congestive heart failure

□ Asthma

□ Pulmonary embolism

□ Diabetes

□ Renal Disease

□ Thyroid

□ High Cholesterol

□ Hepatitis

□ HIV

□ Migraine

□ MRSA

□ GERD

□ Neuropathy

□ COPD

□ IBS

Other: ___________________________________________________________________________________________

OPTIMA VEIN CARE

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Please list any Surgeries and the year you had them □ No previous surgeries

□ CABG

□ Knee Replacement

□ Hip Replacement

□ Appendectomy

□ Cholecystectomy

□ Bunionectomy

□ Hysterectomy

□ Tonsillectomy

□ TSA

Other: ___________________________________________________________________________________________

CURRENT MEDICATIONS □ None

Please list all medicines that you take: Prescription, Non-Prescription, Vitamins and Herbs

________________________ for: _______________ _________________________ for: ________________

________________________ for: _______________ _________________________ for: ________________

________________________ for: _______________ _________________________ for: ________________

________________________ for: _______________ _________________________ for: ________________

SOCIAL HISTORY

Cigarette/Tobacco: # of packs ___________ per day week month former never

Alcoholic drinks: # of glasses ___________ per day week month former never

FAMILY MEDICAL HISTORY

Is there a history in your FAMILY of spider or varicose veins? Yes / No Father/Mother ________________

Is there a history in your FAMILY of DVT or Clotting Disorder? Yes / No Father/Mother ________________

Any family history of diabetes, high blood pressure, stroke, sudden death or other major health issue?

Yes / No Father/Mother ________________

ALLERGIES

□ None □Latex □ Skin Tape □ Drug Allergies:______________________________

The above information has been given to the best of my knowledge:

Patient Signature: ___________________________________________ Date: _________________________

FOR FEMALES ONLY:

□ Currently Pregnant □ Trying to become pregnant □ Breast Feeding Last Menstrual _____________

#of pregnancies: ______ How many children:______ # of stillbirths/miscarriages: ______

Are you currently experiencing any of the following:

□ Pelvic Pain or heaviness □ Veins on upper thighs, vulva or labia

OPTIMA VEIN CARE FINANCIAL AGREEMENT

IF YOU HAVE MEDICAL INSURANCE: We will file claims to your medical insurance company for the services that are

provided by our office. In order for a claim to process correctly, please ensure that the information provided to our

office is current and accurate. If there is a change to your insurance information, please notify us immediately. If a

secondary insurance exists, we will need to be notified for proper claim filing for services given

COPAYS, DEDUCTIBLES & CO-INSURANCE vary for each insurance policy. Any patient portion due will be collected

upon check in. Keep in mind the amounts are estimated as accurate as possible. The exact amount will be known when

the claim has been fully processed through your insurance(s)

Medical insurance coverage is a contract between you and your insurance company. We will not be involved in any

disputes between you and your insurance company(s) regarding COPAYS, DEDUCTIBLES, CO-INSURANCE and etc.

REFERRALS AND AUTHORIZATIONS: A copy of your insurance card(s) is required at the time of Initial service. The card

is descriptive and indicates if a REFERRAL IS REQUIRED and or AUTHORIZATION IS REQUIRED for services. With no

insurance card on file, any filed claims can be denied by your insurance. It is ultimately your responsibility to verify your

coverage for your particular plan. If any claims are denied by your insurance, you will be responsible for any balances.

Accounts that are 90 days past due will be turned over to a collection agency.

24 HOUR CANCELLATION POLICY FEE: Our office requires a 24 hour in advance notice (business days M-F) for any

CANCELLATIONS/RESCHEDULING to avoid fees. The fee is $50.00 and also applies to NO SHOWS for appointments

SELF PAY: A SELF PAY ESTIMATE will be provided to you for our services if you do not have health insurance coverage or

if you are recommended cosmetic treatments by our Physician. In the matter your insurance has an EXCLUSION for our

service(s), you do have the option to be evaluated and treated as a self pay patient. We will collect what is due at the

time of check in.

PAYMENT METHODS: We accept cash, checks and all major credit cards. (VISA, Mastercard, American Express and

Discover Card)

We are committed to providing you with the best possible care. Your clear understanding of our Financial Policy is

important. If you have any questions you may contact us:

Monday-Friday between the hours of 8:00 am – 5:00 pm

Chandler Medical Office Building 485 S Dobson Rd. Ste. 103

Chandler, AZ 85224 P# (480) 899-8930 F# (480) 917-7307

Princess Medical Center 8575 E. Princess Dr. Ste. 117

Scottsdale, AZ 85255 P# (480) 496-2696 F# (480) 264-7012

Estrella Medical Plaza 9305 W. Thomas Rd. Ste. 490

Phoenix, AZ 85037 P# (480) 496-2653 F# (623) 251-5589

Optima Vein Care Notice of Privacy Practice

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THIS NOTICE EXPLAINS HOW YOUR MEDICAL INFORMATION MAY BE USED AND DISCLOSED. PLEASE REVIEW CAREFULLY This notice explains the proper utilization and disclosure from Optima Medical Care regarding your health information. Your health information identifies you. Therefore it is required by law to maintain privacy and protect your health Information. Also, Information on your rights and certain obligations are also explained on this Notice of Privacy Practice The following categories describe various ways to disclose and use your health Information. For Treatment We may disclose your health Information to provide necessary medical treatment(s) and or service(s). This information may be provided to Doctors, Nurses, Technicians and or other personnel who are involved in your medical care. I.e.: An evaluating/treating Physician will need to know if you’re diabetic to insure the proper treatment(s). Diabetes can interfere with healing process. For Payment Your health Information will be disclosed to properly bill/file claims to your health insurance and or third party affiliates for your medical treatment(s)/service(s) to be covered and paid. We may also disclose your health information to obtain prior authorization approval. In the event we may need to give your health care information to a collection agency to collect an outstanding debt. Your health information may be released to a person (family member/friend) involved in your medical care for financial responsibilities. We may also contact your family/friend about your location or general condition or disclose such information to an entity assisting in disaster relief effort For Health Care Operations We may use and disclose Health Information about you for proper health care operations and purposes. These uses and disclosures are necessary to make sure that all of our patients receive quality care. For example, we may use your Health Information to review our staff members. This helps to maintain and guarantee proper management and quality control. We also may disclose information to doctors, nurses, technicians, and other personnel for educational and learning purposes. The entities and individuals covered by this Notice may also share information with each other for purposes of our joint health care operations. Appointments/ Health-Related Benefits and services We may use and disclose Health Information to contact you to remind you of appointment(s) or to contact you to inform you about your treatments or additional information As Required by Law/ To Avert a Serious Threat to Health or Safety We will disclose medical information about you when required to do so by International, Federal, State or Local law Agencies. We may use and disclose Health Information when necessary to prevent a serious threat to your health and safety, or the health and safety of the public or another person. Any disclosure will only be released to the proper authority who may be able to prevent the threat. Business Associates We may disclose Health Information to our Business Associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. For example: We may use Third party billing companies for billing services on our behalf. All of our Business Associates are obligated, under contract with us, to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract. Military and Veterans If you’re a member of the Armed Forces, we may release Health Information as required by military command authorities. We also may release Health Information to the appropriate foreign military authorities if you are a member of a foreign military. Public Health Risks We may disclose Health Information for public health activities and or risks. These activities generally include disclosures to: a person subject to the jurisdiction of the Food and Drug Administration (FDA) for purposes related to the quality, safety or effectiveness of an FDA-regulated product or activity; prevent or control disease, injury or disability; report births or deaths; report child abuse or neglect; report reactions to medications or problems with products; notify people of recalls of products they may be using ; a person who may have been exposed to a disease or may be a risk for contracting or spreading a disease or condition; and the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence and the patient agrees or we are required or authorized by law to make such disclosure.

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Health Oversight Activities We may disclose Health Information to a health oversight agency for activities authorized by law. These oversight activities includes: audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws. Lawsuits and Disputes / Law Enforcement If you are involved in a lawsuit or a dispute, we may disclose Health Information about you in response to a court or administrative order, subpoena, warrant, summons, or similar process: Limited information to identify or locate a suspect, fugitive, material witness, or missing person: about the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement: about a death we believe may be the result of criminal conduct; about criminal conduct on our premises: and in emergency circumstances to report a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime. Inmates If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release Health Information to the correctional institution or law enforcement official. This release would be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety or the health and safety of others; or (3) the safety and security of the correctional institution. How to Learn About Special Protections for HIV Special privacy protections apply to HIV-related information. Some parts of this general Notice of Privacy Practices may not apply to these types of information. If your treatment involves this information, you may contact our Compliance Officer for more information about these protections. Other Uses of Health Information Other uses and disclosures of Health Information not covered by this Notice or the laws that apply to us will be made only with your written permission. For example, except for limited circumstances allowed by federal privacy law, we will not sell your health information to others or use or disclose your health information for certain promotional communications that are considered marketing under federal law, without your written authorization. Once you give us authorization to release your health information, we cannot guarantee that the recipient to whom the information is provided will not disclose that information. You may revoke your authorization at any time by submitting a written request to our Compliance Officer. Your Rights Regarding Health Information About You You have the following rights, subject to certain limitations, regarding Health Information we maintain about you. Right to Inspect and Copy You have the right to inspect and copy Health Information that may be used to make decisions about your care or payment for your care. If we maintain a copy of your Health Information electronically, you also have the right to obtain a copy of that information in the electronic format. You can also request that we provide a copy of your information to a third party that you identify. We may deny your request to inspect or copy your medical information in limited circumstances. If we deny your request, you have the right to have the denial reviewed. We may charge you a fee for the costs of copying and or mailing along with other supply costs associated with your request. Right to Request Amendments If you feel that Health Information we have is incorrect or incomplete, you may ask us to amend the information and you must tell us the reason for your request. You have the right to request an amendment for as long as the information is kept by Optima Medical Care LLC. A request for amendment must be submitted in writing to the Privacy Officer at the address provided at the end of this notice. We may deny your request for an amendment in limited circumstances. If we deny your request, you may have a statement of disagreement added to your Health Information. Right to an Accounting of Disclosures You have the right to request an “accounting of disclosures” of Health Information. This is a list of certain disclosures we make of Health Information in the six years prior to your request. We are not required to account for certain disclosures including

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disclosures for treatment, payment or health care operations, disclosures to you or pursuant to your authorizations. The first list you request within a 12 month period will be free. For additional lists, we may charge you a fee for the cost of providing the list. Right to Request Restrictions You have the right to request a restriction or limitation on the Health Information we use or disclose for treatment, payment, or health care operations. You also have the right to request a limit on the Health Information we disclose about you to someone who is involved in your care, or the payment of you care, like a family member or friend. We are not required to agree to your request. If we agree, we will comply with your request unless we terminate our agreement or the information is needed to provide you with emergency treatment. Right to Be Notified of a Breech You have the right to be notified if a breach occurs that may have compromised the privacy or security of your Health Information. Right to Restrict Certain Disclosures to your Health Plan You have the right to request that we do not disclose Health information to your health plan if that information related to health care items or services for which you have paid out of pocket, in full, at the time that the services is provided. You must notify the practice of your request to not provide Health Information about the service to your health insurance plan. We will agree to such requests unless required by law to disclose that information to the health plan. Right to Request Confidential Communications You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you by mail or at you work phone number. Your request must specify how or where you wish to be contacted. We will accommodate any reasonable request. Right to a Paper Copy of This Notice You have the right to a paper copy of this notice, even if you have agreed to receive this notice electronically. You may request a copy of this notice at any time in phone or person. How to Exercise Your Rights To exercise your rights described in the notice, send your request, in writing, to our Compliance Officer at the address listed at the end of this notice. Changes To This Notice We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for Health Information we already have as well as any information we receive in the future. We will post a copy of the current Notice at each Optima Vein Care location. The end of our notice will contain the Notice’s effective date. Complaints/Questions If you believe your privacy rights have been violated. You may file a complaint with Optima Vein Care. Please contact our Compliance Officer at the address listed at the end of this notice. You will not be penalized for filing a complaint. If you have any questions about this privacy notice, contact our Compliance Officer. Nancy Tena, Compliance Officer 8575 E. Princess Drive Suite # 117 Scottsdale, AZ 85255 Phone#: 480-496-2696 Fax#: 480-264-7012