Vantage Health LLC Vantage Health LLC

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Patient Forms

We would like to take this opportunity to welcome you to the Vantage Urologic Institute and to thank you for choosing our organization for your healthcare needs. Our physicians and staff are committed to providing you with the highest quality healthcare in a comfortable environment.

In order to make your first visit as pleasurable and efficient as possible, please complete our new patient forms and questionnaires prior to your scheduled appointment. You may complete these forms either by using our secure online portal (Your Health File) or downloading and faxing or mailing the completed forms to our office.

Patient’s electing to self-register using our secure online portal can email their request to contact@vantageurology.com. An invitation will be sent to the email address provided with instructions and a link to begin the registration process.

Alternatively, to view the forms listed below, you will need Adobe Reader. You may download Adobe Reader for free at http://www.adobe.com/. Please fax, mail or bring your completed forms with you to our office at the time of your visit.

New Patient Forms

  1. New Patient Welcome Letter
  2. Practice Policies
  3. Patient Registration
  4. Assignment of Benefits
  5. Notice of Privacy Practices and Patients’ Rights (Read)
  6. Acknowledgement of Notice of Privacy Practices and Patient Consent
  7. New Patient Packet – Men
  8. New Patient Packet – Women

Questionnaires

  1. Health History Questionnaire
  2. AUA Symptom Score (AUASS) and Quality of Life (QOL) (Males Only)
  3. Sexual Health Inventory for Men (SHIM) (Males Only)

Medical Records Request

  1. Authorization for Use or Disclosure of Protected Health Information (If Applicable)

Please remember the following items for your first appointment:

  1. Copies of your completed new patient forms and questionnaires
  2. Insurance card(s)
  3. Current medications
  4. Pertinent medical records, operative reports, x-rays, and laboratory results

Also, we request you arrive at least 30 minutes prior to your initial visit so that you may be properly registered and acquainted with our facility and staff.