Appendix B: Forms for the Sclerotherapy Practice

INTRODUCTION

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)

Chart Forms

• Registration: Demographics and insurance information (obtained through practice management system)

• Clinical history: General and vascular: Appendix B Figure 2

• Physical examination, treatment, and progress note: Appendix B Figure 3

• Pretreatment testing request: Appendix B Figure 4

• Duplex ultrasound mapping diagram: Appendix B Figure 5

• Written description would accompany this map.

• Treatment fee schedule and consent: Appendix B Figure 6

• General sclerotherapy information and consent: Appendix B Figure 7