Samples of medical forms are from the authors’ practices and are provided to assist other clinicians in developing their own forms. All materials are copyrighted protected. Always consult with your attorney for any legal form.
Patient Information Forms
General information about venous disease: educational video and brochures (Appendix A)
Individualized practice brochure: professional help recommended
Pre-and posttreatment instructions (Appendix B Figure 1)
Pre- and posttreatment instructions.
Clinical history: general and vascular.
Physical examination, treatment, and progress note.
Preoperative testing request.
Duplex ultrasound mapping diagram and written report.
Treatment fee schedule and consent.
General sclerotherapy information and consent.