Schedule an Appointment Today

San Jose: (408) 837-0024 & Palo Alto: (650) 285-5888

Patient Information Form

  • Patient Information

    Please fill out all relevant fields
  • (If different than primary address)
  • Emergency Contact Information

  • Insurance Information

  • Authorization for Release Information

  • I am authorizing VIP Vein Center to release all medical information (including, but not limited to, information on psychiatric conditions, alcohol and drug abuse) requested by my health insurance carrier, Medicare or any other third-party payers. I authorize VIP Vein Center to release all medical information on to my referring physician and my primary physician. I authorize VIP Vein Center to contact my insurance company or health plan administrator and obtain all pertinent financial information concerning coverage and payments under my policy. I direct the insurance company or health plan administrator to release such information to VIP Vein Center.

    Assignment of Benefits: I request that payment of authorized insurance benefits be made on my behalf to VIP Vein Center. I agree that these provisions will remain in effect until I provide written revocation to VIP Vein Center.

  • (if applicable)

Request a Consultation











By submitting, you agree to our Privacy Policy