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| Vein Center of Charlotte - Patient Registration Form |
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Prior to receiving treatment from the Vein Center of Charlotte, we ask that you fill out a patient registration form. This form provides helpful information to the practice such as your current address, phone numbers (in case we need to contact you), insurance coverage, referring physician's name and address, etc.
We have tried to make this process a little easier by providing the form online. Please print the form, fill it out, and bring with you to your first appointment. It will save you and us a lot of time, so we can focus on the most important thing - your medical care.
Please remember to bring your insurance card(s) with you for your first visit. Payment will be required at the time of service.
Click on the PDF icon below to download the form. Thank you!
Patient Registration Form
Don't have Acrobat Reader? CLICK HERE and follow installation instructions.
What other forms might I need? The following forms would be good to have filled out prior to your office visit:
Medical History Form, Family & Friends Information Release Form
You can also receive information on our Privacy Practices by CLICKING HERE.
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