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Day: September 5, 2024

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      Hope - Vascular and Podiatry

      Dr. Miguel F. Montero
      Vascular Surgery Patient Referral Form
      Please Fax this for to 346-205-0221

        Vascular Surgery Patient Referral Form








        Preferred contact name and number (if other than patient):



        Reason for referral:


        Referred by:







        Questions? Contact client services at 346-541-6421
        7501 Fannin St. Suite 600, Houston, Texas 77054

        Hope - Vascular and Podiatry

        Dr. Brian D. Lepow
        Podriatry Patient Referral Form
        Plase Fax this for to 346-205-0221

          Podiatry Patient Referral Form








          Preferred contact name and number (if other than patient):



          Reason for referral:


          Referred by:







          Questions? Contact client services at 346-541-6421
          7501 Fannin St. Suite 600, Houston, Texas 77054

          Hyperbaric Oxygen Patient Referral

          7501 Fannin St., Suite 600
          Houston, TX 77054

          • 346.541.6421
          • 346.205.0221
          • hcic.io
          Hope - Vascular and Podiatry

            Hyperbaric Oxygen Patient Referral





            Wound details

            Wound Location




            Additional information

            Schedule a meeting

              Interested in becoming part of our growing referral network?
              Please schedule a personalized visit with our business development team.
              Fill this form out to join the growing network of limb preservation specialists.


              Appointment request form:



              Vascular Surgery Patient Referral Form
              Podiatry Patient Referral Form
              Hyperbaric Oxygen Patient Referral
              Schedule a meeting with our senior business development team
              Hope - Vascular and Podiatry

              Registration Form

                How did you hear about us?

                I. Patient information:


















                Emergency Contact:





                **By providing an email you agree to receive updates, news, and general information from Hope Vascular & Podiatry. We respect your right to privacy and will not share your information.

                II. Insurance information:

                (Primary) please complete if other than self (Secondary)













                III. Payment of Benefits:

                I direct payment to Hope Vascular & Podiatry of the Surgical and / or Medical Benefits, if any, otherwise payable to me for their services as described, but not to exceed the reasonable and customary charges for those services.



                IV. Release of information:

                I hereby authorize Hope Vascular & Podiatry to release any information acquired during the course of my examination or treatment








                Past Medical History



                Please indicate if you have had any of the following by marking the corresponding check box:
















                Past Surgical History

                Please indicate if you have had any of the following by marking the corresponding check box:










                Family History Select Family Member

                MG: MATERNAL GRANDPARENTS | PG: PATERNAL GRANDPARENTS | M: MOTHER | F: FATHER | S: SIBLINGS















                Social History Select one








                Home Health Agency



                Review of Symptoms

                Please indicate whether you have experienced any of the following...




















                Medication / Allergy History




                Please list all MEDICATIONS you take routinely (including current and previous chemotherapy):

































                HOPE Vascular and Podiatry

                Consent Form

                1. I hereby authorize, Dr Brian D. Lepow and/or Dr. Miguel F. Montero, and Anner Jimenez, NP to perform upon the named patient the following wound care and/or other treatment: Debride wound, removal of dead tissue, x-ray, labs/drawing blood, respiratory treatment and tests and the use of growth factors or other advanced technologies, as applicable. Dr Brian D. Lepow and/or Dr. Miguel F. Montero, and Anner Jimenez, NP has fully explained to me the expected benefits and complications (from known and unknown causes), attendant discomforts and risks that may arise, as well as possible alternatives to the proposed treatment and the anticipated results if the treatment is not performed. The treatment may include application of wound healing growth factors to improve healing. I have been given an opportunity to ask questions and all of my questions have been answered fully and satisfactorily.

                2. Any specimens/tissues removed may be examined and retained by the testing laboratory and its authorized affiliate for medical, scientific or educational purposes and such specimens/tissues or parts may be disposed of in accordance with accustomed practice.

                3. I acknowledge that no guarantees or assurances have been made to me considering the results intended from the wound care and/or other treatment.

                4. I hereby consent that photographs, tape recordings, videotape and/or movies may be taken of the patient named in connection with the medical and/or other services the patient is receiving. I further consent that a history of my/the patient’s social and medical problems may be taken by HOPE Clinical Innovation Center. Videotapes are used for educational purposes only. Recorded video tapes are not part of my medical record. Such photographs, tape recordings, videotapes, videos and/or histories may be published, shown, exhibited or otherwise used by the provider and its authorized affiliate may deem proper. I understand that neither myself/the patient nor members of my/the patient’s family will be identified by name in connection with any use of this material.

                5. I consent to the use of the information obtained during the course of my wound care treatment and stored in the HOPE Clinical Innovation Center’s database for the purpose of conducting research, and quality management activities. I understand that my identity will not be protected in any displays of this information at any time. I further agree that there are no restrictions placed on you or anyone related to the for the use of this information in the manner described above.

                6. I request that payment to authorized Medicare benefits be made either to me or on my behalf for services furnished to me by the provider. I authorize any holder of medical information about me to be released to the Center for Medicare and Medicaid Services and its agents any information needed to determine these benefits or the benefits payable to related services. I understand that I am responsible for any amount not covered by insurance.

                7. I agree to allow HOPE Clinical Innovation Clinic to send me automated text messages to the number I have provided for appointment reminders and discharge instructions.