PATIENT INFORMATION


Date:
Name:
Date Of Birth :
Social Security #:
Sex :
Marital Status :
Address:
Home Phone:
-
Work Phone:
-
Employer Name :
Employer Address:
Primary Care Physician :
Phone:
-
Spouse Name :
Date of Birth:
Referring Physician:
Referring Physician Phone:
-
Person to Notify in case of Emergency :
Relationship:
Relationship Phone:
-

Primary Insurance
----------------------------------------------------------------------


Insurance Company Name:
Insurance Phone Number :
Policy Number :
Group Number :

Secondary Insurance
----------------------------------------------------------------------


Insurance Company Name (sec) :
Insurance Phone Number (sec):
Policy Number (sec):
Group Number (sec) :


  • Our office maintains a Cancellation Policy to serve our patients in a timely manner.
  • Any missed or cancelled Office Appointment with less than a 24hr notice, will be charged $50.
  • Any missed or cancelled Hospital Appointment with less than a 48hr notice, will be charged $150.

I authorize Vascular & Interventional Specialists and/or VIS Procedure Center full disclosure of all records needed for diagnosis and treatment; benefits will go directly to Vascular & Interventional Specialists; nonpayment of this account will be subject to court costs.

ATTORNEY'S FEES:

The prevailing party in any legal proceeding brought under or with respect to the transaction described in this contract is entitled to recover from the non prevailing party all costs of such proceeding and reasonable attorney's fees.

Signature (Enter Initials) :

About Us

Board Certified and fellowship trained Interventional Radiologists. We carry out minimally invasive endovascular and non-vascular treatments and procedures. Our goal is to work closely with the referring physician, communicate with both the patient and physician... Read More

Our Contacts

  • 100 Medical Center Blvd. Suite 118
    Conroe, Texas 77304
  • _________
  • 125 Medical Park Lane Suite D
    Huntsville Texas 77340
  • _________
    College Park Heart and Vascular Center
    17183 I-45 South, Suites 350 & 360
    The Woodlands, Texas 77385

Opening Hours

Monday - Thursday | 8.00am - 5.00pm

Friday | 8.00am - 12.00noon

Saturday -Sunday | Closed

JoomShaper