Patient Forms

Patient Forms and Resources

If you prefer to complete our patient forms in the comfort of your home, you can download them using the link below. Then just bring them with you when you come for your first appointment at our Utah vein clinic.


Patient Information

Mailing Address
Mailing Address
Line 2 (apt/suite #, etc)
Would you prefer us to remind you of your appointments with Text or Phone Call?
Format xxx-xx-xxxx

Hippa RX Consent

HIPPA consent to VIEW HISTORY of medication prescriptions. I, the undersigned, give consent to RED SANDS VEIN to view my prescription history.

Primary Care Provider


How Did You Hear About Us? (Please mark which options apply)

Copays, co-insurance, and self-pay amounts are due at the time of each visit prior to meeting with the physician/physician
Payment in full is due within sixty (60) days from the date of service. If payment in full is not made as required, then in
additional to all other amounts that may be due I agree to pay a collection fee of up to 40% of the principal amount as
provided by 12-1-11 of the Utah Code Annotated, and further agree to pay all other costs of collection (whether incurred by
Red Sands Vein or its assigns) including but not limited to court costs, reasonable attorney fees, and interest (both pre- and
post- judgement). Any interest due hereunder shall be calculated at a rate equal to 18% per annum and may, as determined
by Red Sands Vein or its assigns: (a) accrue on some or all amounts due and (b) compound as frequently as daily-meaning
that accruing interest may be added to the balance owing as frequently as daily such that it shall thereafter constitute part of
the amount upon which interest accrues during the next accrual period.
I hereby consent to being contacted by telephone at any phone number (including but not limited to wireless/cellular phone
numbers) provided to Red Sands Vein by me or anyone associated with me or acting on my behalf. I understand and agree
that such calls may be initiated by Red Sands Vein or any of its affiliates, agents, contractors or assigns, including but not
limited to billing companies and/or third-party collection agency(ies), and that the methods of contact may include using prerecorded/
artificial voice messages and/or the use of an automated dialing device and/or the use of text messages-some or all
of which may result in data charges. I also consent to receiving emails under the same terms at any email address provided
by me or anyone associated with me or acting on my behalf. In granting each and all of the foregoing permissions, I
understand that I am responsible for ensuring my own level of privacy.