Colorado Springs Vascular, P.C.

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Patient Forms

Click on any form below to download a printable PDF file of the form. The forms cannot be completed on line. Please complete the form in black ink and bring the forms with you to your first appointment along with your insurance card(s). Please arrive at least twenty (20) minutes before your appointment.

For your convenience, all of the forms listed below are available for download in Adobe PDF format. If you are not able to download the forms, you can go to the Adobe website to download and install the software, which will allow you to view and print these forms.

Patient Information Form	Basic patient information, Insurance and responsible party for billing, emergency contact, etc.
Patient History Questionnaire	Patient medical history, family history and Medications
Patient Consent Form	Authorization to release information to specific entities and to leave messages with family members [as applicable].
Release of Information Authorization	Detailed authorization to release information to third parties.
Notice of Privacy Practices	Describes the HIPAA [Health Insurance Portability and Accountability Act] policy for the use and disclosure of Protected Health Information [PHI].

Colorado Springs Vascular, P.C.
175 S. Union Blvd., Ste 320
Colorado Springs, CO 80910
(719) 477-1033
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