Returning Patients - Alaska Vein Clinic

Alaska Vein Clinic

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Instructions for Returning Patients

Whether you’re returning for a six-week procedure follow up, three-month support stocking re-evaluation, or we haven’t seen you in years, you’ve come to the right place!

Instructions for Returning Patients

Whether you’re returning for a six-week procedure follow up, three-month support stocking re-evaluation, or we haven’t seen you in years, you’ve come to the right place!

Step 1:

Please read the Coronavirus Precautions

1. Unless it would present a severe hardship or the patient requires a guardian, only the patient should come to the office. Anyone accompanying the patient should wait in the car or the main lobby of the hospital.

2. All patients should wear a face mask. Please bring a freshly washed face mask from home. If you cannot supply your own, we have a limited supply and will be provided one as long as supplies last.

3. All patients should sanitize their hands upon entering the office.

4. No one should come to the office who has a fever, cough, fatigue, loss of appetite, loss of appetite or smell, or body aches.

5. No should come to the office within two weeks after exposure to someone with a Coronavirus infection.

6. No one should come to the office who has traveled outside of Alaska within two weeks of their appointment.

7. We are not performing cosmetic vein procedures at the present time.

Step 2:

Bring in the following items with you:

Photo ID

Insurance Cards (if insurance has changed since your last visit)

Medication list (if changed since your last visit)

Records of venous procedures done elsewhere, if available.

Step 3:

Update your patient registration, if there have been changes in your information.

Press here if there have been information changes.

Registration UpDate:

Please fill out the Registration Update if you have changed any personal information. You only need to fill those parts that have changed.

AVC Patient Registration Update Form

Patient Name*
First Middle Last Suffix
Date of Birth*
MM slash DD slash YYYY
Age*
Date Last Seen at Alaska Vein Clinic (if known)
MM slash DD slash YYYY
I have the following changes since my last visit:*
- There have been no changes my registration information.
- Mailing Address
- E-mail address
- Main Contact Phone
- Alternate Phone
- Preferred Method of Contact
- Current marital Status
- Employment
- Insurance
Mailing Address*
Street Address Address Line 2 City State ZIP Code
Email
Enter Email Confirm Email
Main Contact Phone*
My main contact phone is a mobile phone capable of receiving text messages.
- Yes
- No
Alternate Phone (if available)
My alternate phone is a mobile phone capable of receiving text messages.
- Yes
- No
My preferred method of contact is
- e-mail
- voice telephone
- text
- any of the above, whatever is convenient
Current marital status
- I am now married.
- I am now Partnered / Cohabitating.
- I am now separated / divorced.
- I am now widowed.
Spouse / Partner Name
First Last
The Alaska Vein Clinic may discuss my medical issues with my spouse / partner.
- Yes
- No
If Divorced, do you still have insurance benefits through you ex-spouse?
- No
- Yes
Employment
I am now
- employed
- self-employed
- unemployed
- retired
- on temporary lay-off
Employer
Brief employment description
I may be called at work:
- Yes
- No
Insurance
I am now:
- insured through myself
- insurred through my spouse / partner
- insured through both myself and my spouse / partner
- uninsured
- other
Other insurance coverage relationship:
Primary Insurance
- Aetna
- Beech Street
- Blue Cross Blue Shield of Alaska
- Cigna
- EBMS
- Federal Blue Cross Blue Shield
- Medicaid
- Medicare
- Moda
- Multiplan
- Premera Blue Cross Blue Shield of Alaska
- Tricare
- United Health Care
- VA
- Other
Other Primary Insurance:
I have still secondary insurance
- Yes
- No
Secondary Insurance
- Aetna
- AARP
- Beech Street
- Blue Cross Blue Shield of Alaska
- Cigna
- EBMS
- Federal Blue Cross Blue Shield
- Medicaid
- Medicare
- Moda
- Multiplan
- Premera Blue Cross Blue Shield of Alaska
- Tricare
- United Health Care
- VA
- Other
Other Secondary Insurance
Consent to treatment / Financial responsibility.
I agree to the Consent to Treatment / Financial responsibility statment..
I consent to treatment necessary for the care of the above-named patient or myself. I hereby authorize the release of any information acquired in the course of this visit or subsequent visits to my insurance providers and referring physicians. I authorize the payment of medical benefits directly to Robert R Artwohl, M.D., P.C. and the Alaska Vein Clinic. I understand that I am responsible for all charges, regardless of my insurance coverage.

Step 4:

Fill our the online forms:

I an established patient returning for:

ClosureFast or Venaseal Follow-Up

Please fill out the following post-procedure follow-up form.

We look forward to seeing you after your procedure to answer your questions and discuss what should come next.

ClosureFast or Venaseal Follow-Up Visit

Today's Date*
MM slash DD slash YYYY
Date of Treatment
MM slash DD slash YYYY
Name*
First Last
What Procedure(s) Were Done*
- ClosureFast (radiofrequency ablation — heat method)
- Venaseal (adhesive ablation — glue method)
Leg(s) Treated*
- Left
- Right
- Both
Discomfort from the Procedure:
- about what was expected.
- less than expected.
- more than expected.
Long-Term Relief of Discomfort
- about what was expected.
- less than expected.
- more than expected.
Cosmetic Outcome
- about what was expected.
- less than expected.
- more than expected.
Please Describe Any Issues You Are Having*
- Residual Discomfort
- Residual Veins
- I am having no residual issues.
Please Describe Any Issues You Are Having Here.
Post Areas of Concern Here (optional):
The Areas of Concern Diagram is to the right on Desktop and Below on Mobile. After completing it, you can download it here.
Accepted file types: jpg, jpeg, png, gif.
I felt adquately informed about the procedure.
- Yes
- No
I felt well treated by the Alaska Vein Clinic.
- Yes
- No
Overall Impressions about the Alaska Vein Clinic. (This may be used anonymously on the AVC website.)
I would be interested in appearing in a TV testimonial ad for the Alaska Vein Clinic
- Yes
- No

Results of Support Stocking Trial

Today's Date*
MM slash DD slash YYYY
Date of Initial Visit*
MM slash DD slash YYYY
Weeks Since Last Visit
Name*
First Middle Last Suffix
Date of Birth*
MM slash DD slash YYYY
Age
Email*
Enter Email Confirm Email
I have worn the support stockings:*
- Yes
- No
Elaborate Your Wearing of Support Stockings, if Necessary
I have taken pain medications*
- Yes
- No
Type of pain medications
Relief with support stockings:*
- Complete
- Partial
- No relief
Elaborate Relief with Support Stockings, if necessary.

Sclerotherapy Follow-Up

Sclerotherapy Follow Up

Today's Date*
MM slash DD slash YYYY
Date of Treatment
MM slash DD slash YYYY
Name*
First Last
What Sclerotherapy Procedure Was Done*
- Ultrasound Guided Sclerotherapy
- Superficial Sclerotherapy
- Both
- Not sure
Leg(s) Treated*
- Left
- Right
- Both
Discomfort from the Procedure:*
- about what was expected.
- less than expected.
- more than expected.
Long-Term Relief of Discomfort*
- about what was expected.
- less than expected.
- more than expected.
Cosmetic Outcome*
- about what was expected.
- less than expected.
- more than expected.
Please Describe Any Issues You Are Having*
- Residual Discomfort
- Residual Veins
- I am having no residual issues.
I believe I need or I would like additional sclerotherapy:
- Yes
- No
- Not sure, I'll decided after I talk to Dr. Artwohl
Please Describe Any Issues You Are Having Here.
Post Areas of Concern Diagram Here (Optional)
The Areas of Concern Diagram is to the right on Desktop and Below on Mobile. After completing it, you can download it here.
Accepted file types: jpg, jpeg, png, gif.
I felt adquately informed about the procedure.
- Yes
- No
I felt well treated by the Alaska Vein Clinic.
- Yes
- No
Overall Impressions about the Alaska Vein Clinic. (This may be used anonymously on the AVC website.)
I would be interested in appearing in a TV testimonial ad for the Alaska Vein Clinic
- Yes
- No

New or Continued Problems

AVC Vein and Medical Questionnaire for Returning Patients

Today's Date*
MM slash DD slash YYYY
Date of Your Appointment
MM slash DD slash YYYY
Name*
First Last
Email*
Enter Email Confirm Email
Date of Birth*
MM slash DD slash YYYY
Age*
I was last seen at the Alaska Vein Clinic (estimate if not sure):*
- Less than six months ago.
- Six months to a year ago.
- Between one and two years ago.
- Two to five years ago.
- Over five years ago.
I've been seen at the Alaska Vein Clinic for:*
Check all that apply
- Cosmetic varicose vein problems.
- Symptomatic varicose vein problems.
- Lymphedema / Lipedema.
- Superficial Thombophlebitis.
- Deep Vein Thrombosis.
- Leg Swelling of Uncertain Causes.
- Other.
- Not sure what I was seen for.
If you like, elaborate on what you have been seen at the Alaska Vein Clinic for:
Prior vein procedure(s) at Alaska Vein Treatment:*
- Radiofrequency Vein Ablation (ClosureFast).
- Laser Vein Ablation (Vencure).
- Adhesive / Glue Ablation (Venaseal).
- Saphenous vein stripping.
- Local excision of varicose veins.
- Superficial sclerotherapy.
- Ultrasound guided sclerotherapy.
- No treatments at the Alaska Vein Clinic.
- I don't remember exactly what I had done.
If necessary, add comments on Prior Vein Treatment here.
Since my last visit I have the following vein issues:*
- Appearance issues.
- Continuing or worsening discomfort.
- Superficial thrombophlebitis.
- Deep vein thrombosis.
- Blood clot to the lung (Pulmonary Embolism).
- Diagnosed with hypercoagulable state.
- Other.
Please describe what issues, if any, you have been having since last being seen at the Alaska Vein Clinic. (optional)
Type of hypercoagulable state
- Factor V Leiden mutation.
- Prothrombin gene mutation.
- Antithrombin deficiency.
- Protein C deficiency.
- Protein S deficiency.
- Elevated homocysteine.
- Other.
Other hyper coagulable state:
What best describes your issue(s):*
- I am having CONTINUED problems in an area that was treated.
- I am having RECURRENT problems in an area that was treated.
- I have having NEW problems in area that was PREVIOUSLY treated.
- I am having NEW problems in an area that was NOT treated.
- I am having CONTINUED or WORSENING problems in an area that has not been treated.
Signs & Symptoms
Aches & Pains
- Both legs.
- Right leg.
- Left leg.
- None.
Heaviness and Tiredness
- Both legs.
- Right leg.
- Left leg.
- None.
Swelling
- Both legs.
- Right leg.
- Left leg.
- None.
Night Cramps
- Both legs.
- Right leg.
- Left leg.
- None.
Rupture & Bleeding from Veins
- Both legs.
- Right leg.
- Left leg.
- None.
Itching
- Both legs.
- Right leg.
- Left leg.
- None.
Burning
- Both legs.
- Right leg.
- Left leg.
- None.
Pigmentations (Discoloration)
- Both legs.
- Right leg.
- Left leg.
- None.
Hardening or Thickening of the Skin
- Both legs.
- Right leg.
- Left leg.
- None.
Open sores / Skin Ulcers
- Both legs.
- Right leg.
- Left leg.
- None.
My symptoms:
are made worse by prolonged standing:
- Yes.
- No.
are worse at the end of the day:
- Yes.
- No.
interfere with exercising or physical activity:
- Yes.
- No.
interfere with my job function:
- Yes.
- No.
are helped with elevation:
- Yes.
- No.
are helped with exercise:
- Yes.
- No.
Post Areas of Concern Diagram Here (Optional)
The Areas of Concern Diagram is to the right on Desktop and Below on Mobile. After completing it, you can download it here.
Accepted file types: jpg, jpeg, png, gif.
Pain Medication
I use pain medication for my leg symptoms:*
- Daily.
- Not everyday but at least once a week.
- Occassionally (less than once a week).
- Rarely ( a few times a year).
- Never.
Type of Pain Medication
- Motrin, Advil or other forms of ibuprofen.
- Tylenol.
- Aleve, Anaprox, Naprosyn, or other forms of naproxen.
- Narcotics/Opioids.
- Other.
Name of pain medication:
Support Stocking Use
I have routinely worn prescription support stockings since my last vein treatment.*
- Yes.
- No.
I have worn support stockings:*
- Off and on.
- Everyday.
- Other
Briefly describe "other" support stocking use
Prior Vein Treatment and Problems:
Since my last visit to Alaska Vein Clinic, I have had vein treatment elsewhere:*
- No.
- Yes.
Where this treatment was done:*
- Laser Vein Center (Center for Vein Restoration) - Dr. Ives
- Alaska Vein Care
- Vein Specialists of Alaska - Dr Bell
- Premiere Vein of Alaska - Imaging Associates
- Alaska Heart Institute
- Other location / Not sure where vein treatment was done.
Elaborate briefly on other location / not sure where vein treatment.
General Medical History
Operations since last visit:*
- No new operations.
- I've had surgery since by last visit.
List of prior operations since last visit.
(Type of operation and year it was performed)
I've developed new medical problems since my last visit:*
- Yes.
- No.
Medical problems
- High Blood Pressure
- Heart Disease.
- Perpheral Vascular Disease
- Diabetes, taking Insulin.
- Diabetes, on oral meds.
- Diabetes, diet controlled.
- Heart Disease
- Cancer in remission
- Cancer being treated
- HIV/AIDS
- Osteoarthritis (wear & tear arthritis)
- Rheumatoid Arthritis
- Lung Disease (e.g. COPD, Chronic Bronchitis)
- Kidney Disease
- Recovered from COVID-19
- Fibromyalgia
- Autoimmune Disease (specify below)
- Gynecological Issues (elaborate below)
Other Medical problems
List other medical problems or elaborate on Items check above.
New Allergies since my last visit:*
- No allergies.
- I have new allergies.
I am allergic or intolerant to:
- Penicillins (Penicillin, Amoxicillin, Ampicillin)
- Cephalosporins (eg Keflex, Ceclor, etc)
- Sulfa drugs
- Tetracyclines
- Latex
- NSAIDS (Ibuprofen, Motrin, Advil, Aleve, Naprosyn, etc)
- Aspirin
- IV Contrast Dye
- Shellfish
- Iodine antiseptics (eg Betadine)
- Local Anesthetics (Lidocaine)
- Mold & Dust
- Adhesive Tapes
- Other Allergies (list below)
Please elaborate on or add Allergies or Intolerances.
Change in Medications*
- No new medications.
- Taking new medications.
- Some medications have been discontinued.
About the change in my medications:
- I will upload my updated list here.
- I will bring my medication list in with me.
- I will write in the changes below
This is my medication list.
Max. file size: 256 MB.
Changes in my medications:
Has any member of your family developed vein problems since last visit?
- No.
- Yes.
Relative with new vein problems:
- First degree relative (father, mother, sister, brother).
- Second degree relative (grandparents, aunts, uncles, half siblings).
- Third degree relatives (cousins, great grandparents).
Type of Vein Problems
- Varicose veins.
- Blood clots.
- Not sure.
- Other.
Please feel free to add any comments here:

Save and Continue Later

Area(s) of Concern

If you like, you can download the leg diagram form below and use it in one of the three ways.

1. Mark your areas of concern with the application you used to open it, save and download it into the form as .pdf or Word (.docx) file.

2. Print it out, mark it, then scan or photograph it and upload the image to the form.

3. Same as choice 2, except just bring it with you at the time of your appointment.

Click Image Below to Download Diagram

Alaska Vein Clinic • 3300 Providence Drive, Suite 309 • Anchorage, AK 99508

Phone: 907-222-6240 • Fax: 907: 907-222-6870

This website was created and is maintained by the Alaska Vein Clinic.

Instructions for Returning Patients

Instructions for Returning Patients

Step 1:

Step 2:

Bring in the following items with you:

Photo ID

Insurance Cards (if insurance has changed since your last visit)

Medication list (if changed since your last visit)

Records of venous procedures done elsewhere, if available.

Press here if there have been information changes.

Registration UpDate:

AVC Patient Registration Update Form

Employment

Insurance

Step 4:

Fill our the online forms:

ClosureFast or Venaseal Follow-Up

ClosureFast or Venaseal Follow-Up Visit

Post Areas of Concern Here (optional):

Results of Support Stocking Trial

Results of Support Stocking Trial

Sclerotherapy Follow-Up

Sclerotherapy Follow Up

Post Areas of Concern Diagram Here (Optional)

New or Continued Problems

AVC Vein and Medical Questionnaire for Returning Patients

Signs & Symptoms

My symptoms:

Post Areas of Concern Diagram Here (Optional)

Pain Medication

Support Stocking Use

Prior Vein Treatment and Problems:

General Medical History

Click Image Below to Download Diagram