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  8888 Summa Avenue
Womack Heart Center
3rd Floor
Baton Rouge, LA 70809
phone: 225-769-4493
email: email@brvsc.com		  

 

 

Patient Registration

Patients please download and print out this PDF Registration Form OR you may PRINT this page, fill out the form, and bring it in to the office. Thank you!

All fields are required (please write N/A for items that are not applicable).

PATIENT LAST   FIRST MIDDLE AGE MALE
FEMALE
MAILING ADDRESS HOME PHONE
CITY STATE ZIP EMPLOYER OCCUPATION
EMPLOYER'S ADDRESS CITY STATE ZIP WORK PHONE
DATE OF BIRTH SS # MEDICARE #
MARITAL STATUS SPOUSE'S NAME

EMAIL ADDRESS:

GUARANTOR RELATIONSHIP BIRTHDATE  
 
ADDRESS CITY STATE ZIP HOME PHONE
EMPLOYER ADDRESS WORK PHONE
PRIMARY INSURANCE CO. ADDRESS
POLICY HOLDER NAME BIRTHDATE GROUP #  
 
POLICY HOLDER EMPLOYER ADDRESS
SECONDARY INSURANCE CO. ADDRESS
POLICY HOLDER NAME BIRTHDATE GROUP #  
 
POLICY HOLDER EMPLOYER ADDRESS
NEAREST RELATIVE (not at same address)
ADDRESS HOME PHONE
FAMILY DOCTOR PHONE
CHIEF COMPLAINT    
   
ALLERGIES? TO WHAT?
YES  NO
ARE YOU PRESENTLY UNDER TREATMENT FOR ANY OTHER ILLNESS OR INJURY?
(Please Explain)
ARE YOU PREGNANT OR IS THERE ANY CHANCE YOU COULD BE? YES  NO
CHIEF COMPLAINT    
   
HOW DID YOU FIND OUT ABOUT Vascular Specialty Center?
To my knowledge the above information is correct. I give my consent for treatment for this illness or injury described herein and I understand that I am financially responsible to Vascular Specialty Centerfor all charges not covered by any and all insurances. If payment is not made at the time services are rendered, adequate provision must be made for payment and additional credit information may be required. I understand that both parents of a minor patient may be asked to sign a statement of financial responsibility and that if a patient is married, under some circumstances, the patient's spouse will be required to sign the statement of financial responsibility. I authorize payment directly to Vascular Specialty Center of any insurance policy benefits payable to me, and I hereby assign all such policy benefits to Vascular Specialty Center.
PATIENT'S SIGNATURE DATE
SIGNATURE OF ADDITIONAL RESPONSIBLE PARTY RELATIONSHIP DATE
Vascular Specialty Center reserves the exclusive right to designate which of its employees shall perform service.

 

 

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 Copyright ©2008-2009 Vascular Specialty Center
8888 Summa Avenue - Womack Heart Center – 3rd Floor • Baton Rouge, LA 70809
225-769-4493 • email@brvsc.com

 

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