Contact - Houston Vascular & Podiatry Surgeons

Vascular Surgery Patient Referral Form

Patient name:

Date of birth:

Patient's phone:

Address:

City:

State:

Zip:

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

Name:

Number:

Reason for referral:

Insurance:

Referred by:

Physician's name (please print):

Office:

Fax:

Referral date:

Date of office visit:

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

How did you hear about us?

Physician referralWebsiteFriend / FamilyOther

I. Patient information:

Name:

Date of birth:

Sex:

Language:

Race:

Ethnicity:

Home address:

City:

State:

Zip:

Marital status:

Home phone:

SS#:

Cell:

Employer:

Work#:

Email:

Emergency Contact:

Name:

Relationship:

Phone#:

**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)

Insurance Co.:

Policy#:

Group#:

Name of guarantor:

Insured's DOB:

Employer (if group policy):

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.

Signed (Insured Person):

Date:

IV. Release of information:

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

Name:

Relationship:

Contact:

Name:

Relationship:

Contact:

Signed (Patient):

Date:

Medication / Allergy History

Pharmacy :

Address:

Are you currently taking Aspirin?
YesNo

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

Name of Medication

Dosage (mg)

How many times daily

Medication Allergies:

Other Allergies:

HOPE Vascular and Podiatry

Consent Form

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

Patient/Agent Signature:

Date:

Witness Signature:

Date:

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Hyperbaric Oxygen Patient Referral

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

Vascular Surgery Patient Referral Form

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

Podiatry Patient Referral Form

Hyperbaric Oxygen Patient Referral

Hyperbaric Oxygen Patient Referral

Schedule a meeting

Registration Form

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

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