Robert F. Merchant, MD, FACS 10685 Professional Circle, Ste B John W. Daake, MD, FACS Reno, NV 89521 (775)-329-3100 www.renoveinclinic.com

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Thank you for making an appointment for a consultation at The Reno Vein Clinic.

• Please plan on arriving on-time for your appointment. If you arrive late we may need to reschedule your appointment.

• COMPLETE THE ATTACHED FORMS BEFORE YOUR APPOINTMENT.

• Any additional communication with your insurance beyond this initial inquiry will be in addition to the complimentary consultation. • Please bring a pair of loose-fitting shorts with you. Spouses are encouraged and welcome to attend the consultation.

We ask that no small children be brought to the appointment.

• On the initial visit you will undergo an extensive evaluation by your vascular surgeon. He will perform an examination which may also require ultrasound testing of your lower extremity venous system. Upon completion of this visit, a clear picture of your vein problem will be obtained and a detailed treatment plan will be recommended. • There is NO charge for the consultation at this time. • If sclerotherapy injections are prescribed for your treatment, it may be possible to perform the first session at the same time as the initial

consultation. If such is your decision, then the fees for sclerotherapy will be discussed and payable at that time. • The Reno Vein Clinic is a provider for a limited number of insurance plans; however, this usually works to your advantage as there is a greater degree of flexibility in determining your co-payment toward any treatments and clinic visits. • The Reno Vein Clinic “opted out” of the Medicare insurance program. As a result, the clinic is prohibited from submitting

a bill to Medicare for any services rendered on your behalf. This applies to Medi-gap programs also. If this applies in your case, please be advised that we can enter into a “private contract” with you for any treatments you wish to undergo.

We look forward to seeing you on _______________________________at_____________________ .

Should you need to cancel your appointment, we require a 24-hour cancellation notice.

Patients who do not keep their appointments or provide 24 hour notice of cancellation will be subject to a deposit of $50.00. This fee will be applied after the first missed appointment or first failure to provide 24 hours notice of cancellation. This pre-payment will be applied to any treatment costs. This is not a billable charge to any insurance company and is the responsibility of the patient.

If a patient misses or cancels 3 times, we reserve the right to dismiss that patient from the care of the Reno Vein Clinic.

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