PATIENT INFORMATION QUESTIONAIRE


Patient Name:
Date:
Date Of Birth :
Have you had a procedure done by Dr. Turley or Dr. Odelowo before? :
Reason For Visit:
Current Medications :
Allergies (Including food/drug/Iodine) :
Current Pharmacy (Name, Ph# & Location) :
Primary Care Physician:
Phone Number
Medical History (Check all Diagnosis you have had in the past):
Family History:
Hospitalization History/Surgery History:
Social History
Amount of Tobacco Use
Amount of Alcohol Use
Amount of Caffeine Use
Amount of Drug Use
Have you ever received a blood transfusion or blood products?
Occupation
Who lives in your household?
Current Symptoms/Signs (Check all that apply)
Have you had any tests, Imaging studies, or other scans prior to your visits

By Signing below, I affirm the above information is accurate to my knowledge.


Patient Signature (Enter Initials) :

Receipt of notice of privacy practices written acknowledgement form

I have read the Privacy Notice and understand my rights contained in the notice. By way of my signature, I provide Endovascular and Interventional Associates with my authorization and consent to use and disclose my protected healthcare information for the purpose of treatment, payment and healthcare operations as described in the Privacy Notice.

**
Signature (Enter Initials) :*
Date

Photo Consent


May we obtain photographs for treatment and follow-ups purpose only?
Signature (Enter Initials):*
Date :

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

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