Peter B. Morgan, M.D.
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3 Peter B. Morgan, M.D. Specialized Vein Care Spider Veins Spider veins are small blue/black veins seen on your legs. They are called spider veins because they appear like spiders. These veins are always cosmetic. Insurance companies never pay for treatment of spider veins. one Star Vein Center is proud to feature the Cutera Excel V laser for cosmetic vein treatments. In some patients the spider veins may have little improvement after one treatment. It may take more than one session. The spider treatment session is twenty five minutes. The session is $ and fee applies for each session. However, we do offer a discount of $50.00 if paid in cash. We can treat spider veins at a later date, not the same time as your procedure. If you have come to see Dr. Morgan with the only issue being spider veins please make that very clear as we do not want you to think that treatment of chronic venous insufficiency will provide resolution of spider veins. Thank you very much for your cooperation. I acknowledge that I have read and understood this form. Signature Date
4 Please understand that Dr. Morgan is contracted by your insurance. Our office MUST follow your insurance guidelines. We will not attempt to do anything outside of your insurance guidelines. If your insurance requires a stocking trail, We will not start a precertification until you have completed the stocking trail requirements. Please be advised, that anytime you have an office visit, ultrasound, or any type of treatment, you will be responsible for any copays or patient responsibilities. If you come in for an ultrasound, and do not wish wait for your results, we will be more than happy to schedule you, AD we will collect your copayon your next visit. Also please note, we try to stay on schedule, but Dr. Morgan pays attention to every patient s needs, therefore sometimes, we may be off schedule. We apologize in advance. Thank you for understanding Patients signature: Date:
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6 one Star Vein Center Peter B. Morgan, M.D. Patient Vein History Form ame: DOB: Date: Sex: Age: M F Insurance Provider: eferring Physician: How Did you hear about us? I. Vascular History Do you have or have you ever been diagnosed with: Deep Vein Thrombosis (DVT) Blood Clots Varicose Veins Superficial Phlebitis (Vein edness/tenderness) Aching/Pain Heaviness Tiredness/Fatigue Itching/Burning Swelling Cramps estless egs Throbbing Skin or Ulcer Problems Does prolonged sitting or standing aggravate your legs? Are your veins getting worse? Do you experience any of the following in your leg(s): How long have you had problems with your veins? Which of the following do you currently do to improve your leg symptoms? Medication for Pain What? Wear Support Hose Date Started: Elevation of egs Family History Have any of your family members had: Varicose Veins Who? Vein Stripping Who? Blood Coagulation Disorder Who? Blod Clots Who?
7 one Star Vein Center Peter B. Morgan, M.D. Past Surgeries Personal Activities ist: Does your work or lifestyle require: Prolonged Standing Periods Prolonged Sitting Periods Do you exercise regularly? Current Medication ist, Dosage and Supplements Allergies: Additional Comments: Complete this section only if you are currently over 65 years of age Have you had a pneumonia vaccine? If yes, when? es o Do you have a living will? If no, would you like a copy of one? es o es o To be completed by all patients Have you had a flu shot? When was your last flu shot?
8 one Star Vein Center Peter B. Morgan, M.D. our personal past medical history, not your family, or anyone else, just your own past medical history Stroke Heart Attack Diabetes High Blood Pressure Kidney Disease iver Disease Tobacco Use Pregnancies Cancer upus Heart Disease STD Do you have any major illnesses not listed above? Signature: Date:
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