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Intake Forms

Please print, fill out and bring with you on the first visit:

Patient Registration Form

Patient Registration Form (Spanish version)

Health Questionarre

HIPAA Form

Insurance Information and Financial Policy Form

NOTICE AND ACKNOWLEDGMENT OF RECEIPT AND UNDERSTANDING

California Vascular & Vein Center Spanish Version

AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION

Address

177 E Houston St
New York, NY 10002

Phone

+(888) 695-9859
+(888) 569-9859

Email

info@example.com
hello@example.com

Book Your Appointment

Bakersfield 01

2808 F Street, Suite A
Bakersfield, CA 93301
Tel: (661) 873-4216
Fax: (661) 873-4218

Hours:

8 am to 4 pm weekdays
8 am to 1 pm on Saturdays
Sunday closed

Milpitas02

995 Montague Expy 213, 2nd floor Milpitas, CA 95035
Tel: (408) 708-4153
Fax No.+1 (408) 889-6150

Hours:

Monday to Wednesday:
9 AM to 4 pm

Expert Care for Healthy Legs

$100 OFF on All Vascular Service

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