Landis Vein Care Clinic - Patient Forms

Please complete the following forms PRIOR to your appointment and bring them with you on the day you are scheduled, along with your picture identification and insurance cards.  Failure to bring completed forms may result in cancellation of the appointment and a $75 late rescheduling fee. Patients arriving more than 10 minutes late will be rescheduled and responsible for this charge as well.

In order to provide a safe working environment we ask that children do not accompany you to your appointment.  Due to the use of equipment such as lasers and ultrasound, please arrange for childcare before your appointment.  In the event that childcare is not arranged, the result will be cancellation of services and a cancellation charge.

Patient Registration
Click to download (pdf format)

 

 

Authorization to Release Medical Records
Click to download (pdf format)

 

 

Patient Vein Questionnaire
Click to download (pdf format)

 

 

Medication List
Click to download (pdf format)

 

 

 

 

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