Documents

New Patient History

Questionnaire for patients seeing Dr. Brazil for the first time. The information provided here will help him in providing you the best care possible. (Please print form, complete and bring with you for your appointment.)

Carotid Questionnaire (Stroke/TIA)

Questionnaire for patients who present with symptoms of possible carotid disease. (Please print form, complete and bring with you for your appointment.)

Varicose Veins Questionnaire

Questionnaire for patients who are seeing Dr. Brazil for varicose veins and associated pain and discomfort. (Please print form, complete and bring with you for your appointment.)

Leg Arteries (PAD) Questionnaire

Questionnaire for patients who are having pain in their legs with walking or at rest. (Please print form, complete and bring with you for your appointment.)

Follow-Up Post-Venous Treatment

Questionnaire to monitor progress of patients who have had treatment of veins. (Please print form, complete and bring with you for your appointment.)

Patient 6-Month to 3-Year Update

Questionnaire to update returning patient’s history if it has been 6 months to 3 years since seeing Dr. Brazil. If it has been longer than 3 years since your last office visit, please complete New Patient History form. (Please print form, complete and bring with you for your appointment.)

Thoracic Outlet Syndrome Questionnaire

Questionnaire for patients who present for evaluation of possible thoracic outlet syndrome. Pain and/or numbness in arms, shoulders, neck. (Please print form, complete and bring with you for your appointment.)

Account & Insurance Information

Account and Insurance Information for reimbursement. (Please print form, complete and bring with you for your appointment.)