I acknowledge that I have reviewed Vein Specialists of the Carolinas Notice of Privacy Practices and have been given an opportunity to ask questions. I may request a copy of the Privacy Practices for my records.


Patient Name ________________________________________________________________

(Please Print)

_______________________________________________  ___________________________

Signature of Patient or Guardian                                            Date


If Guardian, give relationship to patient



I have agreed to let certain individuals participate in discussions and decisions related to my medical care.  Therefore, I hereby give my permission for Vein Specialists of the Carolinas staff to disclose my personal medical information to the following individual:


Name: _________________________________________ Relationship to Patient  ________________________

Name: ______________________________________        Relationship to Patient______________________


Conditions for Disclosure (Check the item(s) that apply):


¨         The practice may disclose my personal health information to the individual(s) above only in my presence.

¨         The practice may disclose my medical information to the individual(s) above in discussions in my presence and when I am not physically present, including disclosures by telephone, facsimile or e-mail or regular mail.

¨         Other Conditions of Disclosure:  _______________________________________________________



I understand that this consent may be revoked by me at any time by written notice to the practice.



Acknowledgement of Patient Rights & Responsibilities and Advanced Directive Policy:


A copy of the Patient Rights & Responsibilities and the policy for honoring advance directives in this outpatient facility have been made available to me for review.  I understand that if I have a living will or Do Not Resuscitate Order that it will be suspended for any outpatient elective procedure that is completed in this center.


Patient Name: _______________________________________________________________

(Please Print)

Signature of Patient: _____________________________________Date:_________________





Witnessed by: __________________________________________ Date:_________________

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