New Patient Paperwork

New Patient Paperwork

In order for us to see you, all of the required questions must be answered. This form is rather long, so please make sure that you have enough time in order to complete it. Some questions will be repeated for legal purposes. You will be asked to attach your directive to physicians (living will) and your durable power of attorney for healthcare. Make sure that you have those files available on this device before starting the form. If you do not have those two items available to you as this time, you can also bring copies with you on the day of your appointment. Alternatively, you can download and print the PDF version of this form and then bring the completed version with you on the day of your appointment. Please note that additional forms not included in either the PDF version or this online version may still be required for completion on the day of your appointment.

Which I-Vascular Center location will you be visiting?
Patient Name
Patient Name
First
Last
Gender
Address
Address
City
State/Province
Zip/Postal
Country
Emergency Contact Name
Emergency Contact Name
First
Last
Emergency Contact #2 Name
Emergency Contact #2 Name
First
Last
Referring Physician Name
Referring Physician Name
First
Last
Referring Physician Address
Referring Physician Address
City
State/Province
Zip/Postal
Country
Is this an HMO/Referral Required?
Is this an HMO/Referral Required?
Contagious Illness
Immunizations & Vaccinations
Check if you have, or have had, any problems in the following areas:
Have you ever had a blood transfusion?
Do you have an advanced directive to physicians (living will)?
Maximum upload size: 516MB
Do you have a durable power of attorney for healthcare?
Maximum upload size: 516MB
Have you ever been to a counselor or psychiatrist?
Have you ever been treated for a psychiatric disorder (depression, bipolar disorder, or schizophrenia)?
Do you have trouble sleeping?
Have you had a D&C, Hysterectomy, or Cesarean Section?
Any urinary tract, bladder, or kidney infections within the last year?
Any blood in your urine?
Any problems with control of urination?
Experienced any recent breast tenderness, lumps, or nipple discharge?
Do you usually get up to urinate during the night?
Do you feel pain or burning during urination?
Any blood in your urine?
Have you had any kidney, bladder, or prostate infections within the last 12 months?
Do you have any problems emptying your bladder completely?
Do you drink alcohol?
Have you ever had any blackouts?
Did you have any severe types of withdrawal from the alcohol (known as DTs or Delirium Tremens)?
Did you attend rehabilitation (AA or counseling)?
Do you CURRENTLY use tobacco?
Have you EVER used tobacco?
Do you have any tattoos?
What kind? (Please select all that apply.)
Do you use any illegal drugs (not prescribed by a doctor or pharmacist)?
Have you ever shared needles?
Have you ever used any illegal drugs in the past?
I authorize and direct Dr. Anwar Gerges and/or other I-Vascular Center health care professionals to perform any necessary diagnostic tests and evaluations, as deemed medically indicated, on myself. I understand that any testing to be done and/or treatment to be given will be explained to me prior to the performance of the exam, and that I may ask questions about such testing.
I hereby authorize payment directly to I-Vascular Center for all payment or reimbursements due from individual or group insurance benefits otherwise payable to me. I also understand I am financially responsible to I-Vascular Center for the charges not covered by the assignment of benefits and the 20% of the allowed charges not covered by Medicare. All professional services rendered are charged to the patient. Necessary forms will be completed to help expedite insurance carrier payments. However, the patient is responsible for all fees regardless of insurance coverage. It is also customary to pay for services when rendered unless other arrangements have been made in advance with our business office.
I hereby authorize I-Vascular Center to release any information requested by my insurance company or representatives.
Some of the following requested PATIENT INFORMATION may have already been asked, but is required to be filled out again in order to authorize the release of your medical records.
Name
Name
First
Last
Address
Address
City
State/Province
Zip/Postal
Country

I-VASCULAR CENTER OF SAN ANTONIO
19234-B Stone Hue
San Antonio, TX  78258
Telephone: 210-481-9544
Fax: 210-481-9545

 

I-VASCULAR CENTER OF EL PASO
11989-D Pellicano Drive
El Paso, TX  79936
Telephone: 915-855-6508
Fax: 915-855-6509

 

I-VASCULAR CENTER OF ABILENE
6300 Regional Plaza, #475
Abilene, TX  79606
Telephone: 325-268-4040
Fax: 325-268-4041

Please release a copy of all my medical records, including but not limited to, progress notes, operative notes, laboratory results and diagnostic tests.
We are committed to providing you the best available medical care. Our personnel will be pleased to discuss our fees and this policy with you at any time. Our professional relationship will be enhanced by your clear understanding of our Financial Policy. Thank you for your review and acceptance of this policy. – All new patients must complete our Patient Information Paperwork before seeing the doctor. – Full payment for our services is due at the time of service, unless other mutually agreed upon arrangements are made with our office staff. – INSURANCE You are responsible for timely payment of your account. Insurance is a contract between you and your insurance company. We are NOT a party to this contract, nor can we become involved in disputes between you and your insurer regarding deductibles, co-payments, covered charges, secondary insurance, “usual and customary” charges, etc. We cannot be held responsible to know every plan and every payment that will be made. There are some procedures done in our offices that are not surgical procedures, but we are required by the insurance guidelines to report the procedure under an insurance code which your insurance company may classify as surgery. If these procedures go toward your deductable, you will be billed for the charges. Our involvement will be limited to supplying factual information to facilitate claim processing. – HMO and PPO Co-payments will be required to be made at the time of your visit, as well as deductibles, when applicable. – MEDICARE We are a participating Medicare provider, thus we accept assignment on your claims. We are required by Medicare to file your claims for you. Medicare will pay us directly and provide you an Explanation of Benefits (EOB) detailing allowances, payments, or denials. – THIRD-PARTY (NOT HMO/PPO) OR SUPPLEMENTAL (SECONDARY) We do not file claims to companies for which we are not providers or with which Medicare does not coordinate benefits. We will provide you with the information you need to submit your primary or secondary claim. I have read and agree to accept the Financial Policy as set forth by I-Vascular Center.

We strive to provide our patients with exceptional medical care and we make every effort to accommodate our patients’ scheduling needs. Patients who: (i) do not show up for scheduled appointments, (ii) arrive late for scheduled appointments, or (iii) cancel scheduled appointments without providing at least twenty-four hours advance notice inconvenience other patients who need timely access to medical care. We would like to remind our patients of our policy regarding missed, late, and cancelled appointments.

If a patient is unable to keep his or her scheduled appointment, please notify us at least twenty-four hours in advance of the appointment by calling the appropriate I-Vascular Center location below:

San Antonio – 210-481-9544
El Paso – 915-855-6508
Abilene – 325-268-4040

Patients who do not reach a member of our staff should leave a detailed voicemail message on our answering machine or with our answering service and a member of our staff will promptly return each patient’s call or email to reschedule his or her appointment.

No Shows aka Missed Appointments: A “no show” is defined as a patient who fails to show up for a scheduled appointment without calling to cancel an appointment.

Late Cancellations: A patient is deemed to have cancelled late if a patient cancels his or her appointment with less than twenty-four hours advance telephone or email notice.

Late Appointments: A patient is deemed to have arrived late to his or her appointment if such patient has not arrived by the scheduled appointment time, regardless of whether a patient calls in advance to notify us that he or she may be late.

We reserve the right to discontinue providing care to patients who miss two or more appointments or who cancel two or more appointments late by providing less than twenty-four hours advance notice. There will be a $35.00 late cancelation fee as well as a $35.00 No Show fee. We also reserve the right to discontinue providing care to patients who are late three or more appointments. This policy is applicable to all of our patients, regardless of race, religion, color, sex, age, disability, national origin, sexual orientation, genetic makeup, or any other basis or protected class covered by federal, state, or local law.

These questions are being asked to assess the likelihood of you having a common disease often linked to other vascular conditions and to allow our doctors the best opportunity to treat your needs.

Do you experience any pain in your legs or feet while at rest?
Do you have uncomfortable aching, fatigue, tingling, cramping, or pain in your feet, calves, buttocks, hip, or thigh while walking or exercising?
Does the pain go away when you stop walking or exercising?
Do your feet get pale, discolored, or bluish at any time during the day?
Do you have an infection, skin wound, or ulcer on your leg or foot that is slow to heal over the past 8-12 weeks?
Do you have high cholesterol or other blood lipid (fat) problems or require cholesterol medication?
Do you have high blood pressure or take medication to reduce your blood pressure?
Do you have diabetes?
Do you currently or have you ever smoked tobacco?
Do you have a history of stroke or mini stroke (TIA)?
Do you have a history of heart disease (heart attack)?
Do you have a history of carotid stenosis, abdominal aortic aneurysm (AAA), and/or stent placement?
Do you have chronic kidney disease?
Have you had any of the following associated symptoms?
Please select all associated conditions that apply.
Please select all prerenal causes that apply.
Please select all vascular causes that apply.
Classification of renal failure?
Please select all complications of renal dysfunction that apply.
Please select all treatments of renal failure that apply.
Please select all renal replacement therapies that apply.
Please select all preparations for hemodialysis that apply.

Three Convenient Texas Locations:

EL PASO

Next to Davita/El Paso Kidney
11989 Pellicano Dr., Suite D
El Paso, TX 79936
Phone: 915-855-6508
Fax: 915-855-6509
Email

DIRECTIONS

YouTube Español

SAN ANTONIO

Medical Park at Stone Oak
19234 Stonehue
San Antonio, TX 78258
Phone: 210-481-9544
Fax: 210-481-9545
Email

DIRECTIONS

YouTube Español

ABILENE

Hendrick Health #1
6300 Regional Plaza, #475
Abilene, TX 79606
Phone: 325-268-4040
Fax: 325-268-4041
Email

DIRECTIONS

YouTube Español

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Treatments

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