Steven L. Kaufman, M.D., Ph.D., F.A.C.S.

1136 East Stuart Street, Suite 4102, Fort Collins, CO 80525 phone: (970) 498-8346 or toll free: (866)884-VEIN fax: (970) 419-8346 www.totalvein.net

To Our New Patient:

We at Total Vein Care wish to take a moment to welcome you to our practice and

thank you for choosing us. We look forward to helping you address your vein health

concerns, and we will do all we can to ensure you a successful resolution.

Our goal is to provide the highest quality of care possible in a friendly and caring envi-

ronment. We appreciate the trust and confidence you have placed in us.

In an effort to make your visit a pleasant and efficient one, enclosed are several patient

information forms to be completed before your initial appointment.

If your insurance company requires a referral or authorization for you to see a special-

ist, please contact your primary care physician for the necessary referral or authoriza-

tion.

Your visit or co-pay is payable at the time of service by cash, check, or credit card. If

you have insurance, please bring your insurance card and a photo ID to your first visit

so that we can bill your insurance company.

Appointments can be rescheduled by calling our office at 970-498-8346. We request

the courtesy of 24 hours notice for cancellations. Please keep in mind we have patients

waiting sometimes for weeks to be seen. A last minute

cancelled appointment or just not showing up prevents us

from being able to offer that appointment time to some-

one else.

We look forward to seeing you at our office. Thank you for

giving us the opportunity to serve you.

Sincerely,

Steven L. Kaufman, M.D., Ph.D., F.A.C.S

Patient Information Form

Patient Name ______________________________Social Security # ________________

Birth Date ___________________________Marital Status ________________________

Home Phone _________________________________Cell Phone __________________

Work Phone ___________________________Employer __________________________

Patient Address __________________________________________________________

City ______________________________________ST _______Zip ________________

Email Address ___________________________________________________________

Drivers License Number ______________________________

Spouse’s Name _____________________________________Phone # ______________

Race _________________Ethnicity _________________Preferred Language ________

Emergency Contact: Name ______________________________Phone # ____________

Name of Insurance Carrier __________________________________________________

Primary Care Physician ____________________________Referral Source ___________

LIFETIME AUTHORIZATION: I REQUEST THAT PAYMENT OF AUTHORIZED INSURANCE BENEFITS

BE MADE ON MY BEHALF FOR SERVICES RENDERED TO ME. I AUTHORIZE STEVEN L. KAUFMAN MD

TO RELEASE INFORMATION NECESSARY TO PROCESS INSURANCE CLAIMS AND OBTAIN PRE-

DETERMINATION.

ASSIGNMENT OF BENEFITS: I HEREBY ASSIGN STEVEN L. KAUFMAN MD., PhD., PC ANY INSURANCE

OR THIRD PARTY BENEFITS AVAILABLE FOR HEALTH CARE SERVICES PROVIDED TO ME. I AGREE TO

FORWARD ALL HEALTH INSURANCE OR THIRD PARTY PAYMENTS THAT I RECEIVE FOR SERVICES

RENDERED IMMEDIATELY UPON RECEIPT.

PATIENT SIGNATURE ______________________________DATE____________________________________

Financial Policy

Total Vein Care is dedicated to providing you the best care possible. If you have health insurance, we are

committed to helping you receive your maximum allowable benefits. Therefore:

As a courtesy, we will attempt to verify your benefits with your insurance company via phone, and when

necessary, we will obtain pre-authorization or pre-determination of benefits prior to your procedure. You

share in the responsibility by knowing what your plan covers and for verifying your benefits with your

insurance company. We will do our best to obtain a financial estimate regarding your responsibility of

procedure charges, and this information is based on the verbal information obtained from your insurance

company. Because these are estimates only, the final cost for services is not fully known until the claim has

been adjudicated by your insurance. The estimated charges that are your responsibility pursuant to your

insurance policy are due the day of your procedure. We accept cash, checks, MasterCard, Visa,

Discover and American Express. We also accept Care Credit.

Please note the estimate we obtain is for your procedure only. It does not include any charges that may

occur from the New Patient visit or Post-Op appointments. Again, we have no control over how the

insurance companies pay or apply charges.

TVC will file an insurance claim with your insurance company and an explanation of benefits will be sent

to you and TVC. Any overpayment by you will be refunded and any amount owed by you will be due at

this time. We emphasize our relationship is with you and not your insurance company. In the event that

your insurance carrier denies payments or pays less than expected, you are responsible for any balance on

your account. The insurance company’s decisions and payment amounts are not within our control;

however, we are happy to assist you in the insurance appeal process. If it becomes necessary to collect

your unpaid balance using a collection agency, you will also be responsible for any charges incurred as a

result of the collection activity (usually 20-50% of unpaid amount) as well as any legal or court fees

incurred.

Failure to cancel your office visit within 24 hours of your scheduled appointment will result in a $50

charge. Failure to cancel your surgery within 48 hours of your scheduled surgery will result in a $300

charge. Any cancellation fees are due by you and are not billable to your insurance company.

Returned checks are subject to a $25 service fee. Repayment will be required in cash, money order or credit

card only.

AGREEMENT

I, (print name)_________________________________________understand that I am financially responsible for

services rendered and any balance after insurance processing. I have read and understand the terms and conditions

of my financial obligation and agree to honor the office policies outlined above.

Patient Signature: ____________________________________________Date:___________________

STEVEN L. KAUFMAN, M.D., Ph.D., F.A.C.S.

1136 EAST STUART ST. STE. 4102

FORT COLLINS, CO. 80525

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT

I understand that, under the Health Insurance Portability & Accountability Act of 1996

(HIPAA), I have certain rights to privacy regarding my protected health information. I

understand that this information can and will be used to:

Conduct, plan and direct my treatment and follow-up among the multiple health

care providers who may be involved in that treatment directly and indirectly.

Obtain payment from third-party payers.

Conduct normal health care operations such as quality assessments and physician

certifications.

I have received, read and understand your Notice of Privacy Practices containing a more

complete description of the uses and disclosures of my health information. I understand

that this organization has the right to change its Notice of Privacy Practices from time to

time and that I may contact this organization at any time at the address above to obtain a

current copy of the Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is

used or disclosed to carry out treatment, payment or health care operations. I also

understand you are not required to agree to my requested restrictions, but if you do agree

then you are bound to abide by such restrictions.

Patient Name_____________________________________________________________

(Print)

Relationship to Patient_____________________________________________________

Name of person (family member or close friend) you approve to receive your personal

information______________________________________________________________

________________________________________________________________________

Signature________________________________________________________________

Date____________________________________________________________________

OFFICE USE ONLY I attempted to obtain the patient’s signature in acknowledgement on this Notice of Privacy

Practices Acknowledgement, but was unable to do so as documented below:

Date:___________________ Initials:__________

Reason:_________________________________________________________________

Vein Health History

Please Check All That Apply:

Right Left

Heaviness/Fatigue

Pain/Aching

Severity of Pain ___ Mild (1-3) ___ Moderate(4-6) ___ Severe(7-10)

Quality of Pain ___ Achy ___ Crampy ___ Dull ___Sharp ___ Throbbing

Spider Veins

Varicose Veins

Swelling/Edema

Severity of Edema ___ Mild ___ Moderate ___ Severe

Skin Discoloration

Restless Legs

Itching

Burning

How long have you had symptoms?

Is one leg worse than the other? ____ R ____ L ____ Same

Leg Ulcers: (Check All That Apply) Right Left How long have ulcer(s) been open?

Active:

Healed: How long did it take to heal?

Bleeding from veins:

How long since last episode? Require Transfusion?

Vein History: (Check all that apply) Right Left

Phlebitis How long ago? # of episodes:

Deep Vein Thrombosis How long ago? # of episodes:

Pulmonary Embolus

Trauma to Legs

Prominent labial/vulvar veins

Prominent abdominal veins

Pelvic pain w/ prolonged sitting

Pelvic pain w/ intercourse

Have you had a work-up for clotting problems? ____ Yes ____ No

Diagnosis of Lymphedema? ____ Yes ____ No

Symptoms are worsened by: Symptoms interfere with my daily living:

___ Prolonged standing ___ Premenstrual ___ Work ___ Long car ride

___ Prolonged sitting ___ Pregnancy ___ Leisure Activity ___ Childcare

___ Walking/Exercise ___ After Exercise ___ Routine Activity ___Sleep

___ Heat ___ Air Travel

Conservative measures attempted to control symptoms: **Compression Stocking Use:

___ Leg Elevation ___ Therapeutic Compression Stockings

First Used: Use Currently?:

___ Exercise -Times per week _________

___ Warm Soaks # of years used: Compression Strength: ___ 15-20 mm ___ 20-30 mm ___ 30-40 mm

___ Weight Loss ___ Cold Soaks # of months used:

___ Avoidance of prolonged sitting/standing

___ Pain Medications: Months used continuously in past year:

**At least 3 months recent continuous stocking use is required for ablation preauthorization for most insurances**

I have achieved relief of symptoms with:

___ Leg Elevation ___ Exercise ___ Weight Loss ___ Avoidance of prolonged sitting or standing

___ Therapeutic compression stockings ___ Warm Soaks ___ Cold Soaks ___ Pain Medication

Prior Vein Treatments: If so, when? __________________________ By whom? ________________________________

___ Injection Sclerotherapy ___ Radiofrequency Closure

___ Ultrasound Guided Sclerotherapy ___ Laser Ablation

___ Vein Stripping ___ Phlebectomy

___ High Ligation ___ Laser/Radio frequency surface treatment of spider veins

Medical History: Years Years Years

___ Aortic Aneurysm ___ Gout ___ Migraine Headaches w/ Aura

___ Anemia ___ Heart Disease ___ Mitral Valve Prolapse

___ Arthritis ___ Heart Murmur ___ Osteoporosis

___ Asthma ___ Hepatitis Type ___ ___ Pace Maker

___ Atherosclerosis ___ High Cholesterol ___ PAD/Poor Circulation

___ Blood disorders ___ HIV ___ Patent Foramen Ovale

___ Blood Clot ___ Hormone Problems ___ Peptic Ulcer Disease

___ Bronchitis/Emphysema ___ Hypertension ___ Prosthetic Heart Valve

___ Cancer of ___________ ___ Hypothyroidism ___ Pulmonary Embolus

___ Cirrhosis ___ Irritable Bowel Syndrome ___ Seizures

___ Crohn’s Disease ___ Kidney Disease ___ Stroke/TIA

___ Depression ___ Liver Disease ___ Superficial Thrombophlebitis

___ DVT ___ Lumbar Spine Disease ___ Trauma to Leg(s)

___ Diabetes ___ Lupus ___ Ulcerative Colitis

___ Diverticulosis ___ Lymphedema ___ Other medical problems:

___ GERD/Reflux ___ Migraine Headaches

Female Medical History:

___ Pregnancies How Many? _____ ___ Pregnant now/planning pregnancy soon

___ Vaginal Deliveries How Many? _____ ___ Currently Breastfeeding

___ C-Section How Many? _____ ___ Contraceptives

___ Stillbirth/Miscarriage How Many? _____ ___ Hormone Therapy

Vaccination History:

Have you received the Influenza Vaccine? __ Yes __ No If so, when?

Have you received the Pneumonia Vaccine? __ Yes __ No If so, when?

Surgical History: Year Year Year

___ Appendectomy ___ Hernia Repair __R __L ___ Prostate Surgery

___ Breast Surgery __R __L ___ Hip Replacement __R __L ___ Skin Cancer Surgery

___ C-Section ___ Hysterectomy ___ Thyroid Surgery

___ CABG ___ Knee Replacement __R __L ___ Tonsillectomy

___ Cholecystectomy ___ Lung Resection __R __L ___ Other Surgery:

___ Hemorrhoidectomy ___ Plastic Surgery

Family History:

Is there a history in your family of spider or varicose veins?

___ Mother ___ Siblings ___ Grandparents

___ Father ___ Aunt/Uncle ___ Child

Is there a history in your family of deep venous thrombosis, stroke or clotting disorders? (Note which)

___ Mother ___ Siblings ___ Grandparents

___ Father ___ Aunt/Uncle ___ Child

Do any major medical problems run in your family? Include consideration of the following: diabetes, heart disease, respiratory

problems, high blood pressure, kidney disease, cancer, bleeding problems, breast problems, thyroid problems, thyroid problems,

or gastrointestinal problems. Please list your primary relatives and the status of their health:

Age Health Problems If deceased, age at death Cause of death

Father

Mother

Siblings

Brother Sister

Brother Sister

Brother Sister

Children

Social History:

Marital Status: ___ Single ___ Married ___ Divorced ___ Widowed

Children: ___ Yes ___ No Number of Children: ___

Occupation: _______________________________________ ___ Full-Time ___ Part-Time

Job w/ Prolonged: ___ Heavy Lifting ___ Repetitive Movement ___ Standing

___ Moderate Lifting ___ Sitting ___ Walking

Alcohol Use: ___ Never ___ Yes ___ Drinks/week ___ # Per Occasion

Street/Recreational Drug Use:

___ Never ___ Within last 90 days

Smoking/Tobacco Use:

___ Never ___ Quit ___ # of years ago

___ Yes ___ Packs/day

___ Total Years Smoked

___ Age Started ___ Have you ever thought of quitting? ___Y ___N __Are you ready to quit? ___Y ___N

Medication Allergies: ____ None ____ Yes

If yes, to what and what was your reaction?

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Prior reaction to Lidocain, Iodine or Latex? ____ None ____ Yes If yes, reaction? __________________________

Medications with dosage and schedule (or frequency) ___ None

_____________________ ________________________ _______________________ ________________________

_____________________ ________________________ _______________________ ________________________

_____________________ ________________________ _______________________ ________________________

_____________________ ________________________ _______________________ ________________________

Review of Systems (Please check all that apply):

Constitutional Symptoms: Respiratory: Cardiovascular: Integument:

__ Problems w/ general health __ Chronic/Freq. cough __ Chest Pain __ Rashes

__ Recent weight loss __ Cough/spit up blood __ SOB with walking __ Skin lesions

__ Recent weight gain __ Wheezing __ SOB while lying down __ Ulcers

__ Fever __ Swelling in legs/ankles __ Itching

__ Fatigue Gastrointestinal __ Palpitations __ Heavy sweating

__ Night Sweats __ Difficulty/pain swallowing __ Hair loss

__ Heartburn GU- Male: __ Easy skin bruising

Eyes __ Nausea __ Infection of penis __ Eczema

__ Decreased vision __ Vomiting of blood __ Impotence

__ Loss of vision __ Duo/gastric ulcer __ Enlarged prostate Neurological

__ Discharge __ Indigestion __ Penile discharge __ Convulsions

__ Double vision __ Jaundice __ Infected prostate __ Dizziness

__ Eye Pain __ Hemorrhoids __ Infection of testicle __ Fainting spells

__ Floaters __ Rectal bleeding __ Loss of consciousness

__ Red Eyes __ Pain on defecation GU- Female: __ Frequent headaches

__ Tears __ Black tarry stools __Irregular periods __ Migraines

__ Constipation __Vaginal discharge __ Disturbances of vision

ENT/Mouth __ Diarrhea __ Nipple discharge __ Disturbances of smell

__ Sore throat __Changes in bowel habits __ Hernia __ Disturbances of taste

__ Hoarse voice __ Abdominal pain __ Difficulty speaking

__ Hearing loss Musculoskeletal __ Involuntary movement

__ Tinnitus (ringing in ears) Endocrine: __ Hip Pain __ Tremors

__ Sinus problems __ Heat intolerance __ Knee Pain __ Abnormal numbness

__ Cold intolerance __ Ankle Pain __ Drooping of face

__ Altered menses __Shoulder Pain __ Nervousness

__ Fatigue __ Wrist Pain __ Mental Illness

Psychiatric: __ Excessive thirst __ Back Pain

__ Anxiety __ Excessive urination __ Muscle spasms Allergy/Immunology:

__ Depression __ Steroid use __ Decreased range of motion __ Rashes

__ Mood swings __ Blood in urine __ Itching

__ Insomnia __ Pain/burning w/ urination Blood/Lymphatic System: __ Hives

__ Hyperactivity __ Frequent/reoccurring bladder infections

__ Enlarged Lymph nodes __ Recurrent infections

__ Night sweats __ Kidney infections __ Fever __ Other: __Difficulty passing urine __Bruising

__ Urinating more than 1 time per night

__Bleeding Tendencies

__ Incontinence __Chronic Sores

Do you have an Advanced Directive? ___Yes ___No If yes, do you have a designated medical decision maker? ___Yes ___ No