Naples Vascular Specialists

Available Forms

Portal Medical Records Release Portal New Patient Registration Portal New Patient Registration Financial Policy Portal New Patient Registration Financial Policy and Assignment of Benefits Portal New Patient Registration Privacy Policy

Portal New Patient Registration

Patient Registration

ANY AREA THAT HAS A (*) MUST BE FILLED OUT. THIS AREA CAN NOT BE LEFT BLANK. IF LEFT BLANK FORM WILL NOT SEND AND IT WILL MAKE YOU FILL IT OUT AGAIN. PLEASE ALSO FILL OUT THE FINANCIAL POLICY AND PRIVACY POLICY FORMS.

First and Last name *

Please type First and Last name

Date of Birth *

SSN

Social Security Number

Gender *

Male

Female

Race

Preferred Language

Local/Primary Address *

Alternate Address

Primary Phone # *

Mobile/Cell Phone #

Alternate Phone #

Email Address

Primary Insurance

Name of Insurance, ID# and Insurance holder name and date of birth

Secondary Insurance

Name of Insurance, ID# and Insurance holder name and date of birth

Emergency Contact Information *

First and Last name, Relationship to the patient and Phone #

Patient Signature *

TYPE First and Last name and Date

Medical History

Referring Provider

Primary Care Provider

Other Doctors/Providers

Pharmacy

Name, Address, Phone number and Fax

Reason for your visit *

Medical History

List medical conditions/diagnoses

Surgical History

List all prior surgeries/procedures (include date performed)

Review of Systems - Please check if you have any of the Following

If none of these pertain to you please select N/A.

General

Fevers

Chills

Night Sweats

Weight Loss

Fatigue/Malaise

N/A

HEENT

Loss of Hearing

Blurry vision/loss of vision

Glaucoma

Retinopathy

Nosebleeds

Hoarseness of voice

Difficult/painful swallowing

N/A

Cardiovascular

Pulmonary

Cough

Blood in cough/sputum

Shortness of breath

Wheezing

N/A

Genitourinary

Blood in urine

Painful urination

Incontinence

Kidney stones

Kidney disease

Prostate enlargement (BPH)

Impotence

N/A

Gastrointestinal

Neurological

Musculoskeletal

Joint pain or swelling

Arthritis

Muscle pain

Back pain

N/A

Hematological

Immune/Lymphatic/Skin/Infectious Disease

Social History

Do you smoke

Never

Former

Current smoker

Former smokers:

What year did you quit?

How many years did you smoke?

How many packs per day?

Current smokers:

How many years have you smoked?

How many packs per day?

Do you drink alcohol?

Yes

How many drinks per day/week/month?

Do you use illict or recreational drugs?

Yes

If yes, what type?

Do you do regular physical exercise?

Yes

If yes, what type and frequency?

Marital status

Single

Married

Domestic Partner

Divorced

Widowed

Do you work?

Yes

Retired

Disabled

If yes, what is your occupation?

If retired what was you former occupation?

Residency

I live here full time

I live here seasonally

If seasonally where do you also live?

Do you have an advanced direcrive?

Yes

Living will

Family History- Please list familial medical conditions (parents/siblings/children)

Family Members

List Family Member, Living/Deceased, Age, and Medical Conditions

Allergies- Please list medications/drugs that cause an allergic reaction to you.

Allergies

List Medication and Reaction

Medications-Please list all medications and supplements that you are taking currently.

Medications

List Medication Name, Dosage and Frequency

* Required field