Patient Forms

For patients dealing with the challenging effects of lumbar spinal stenosis, the MILD procedure provides a modern, minimally invasive solution designed to reduce pain and help restore movement.

A new opportunity at living a pain free life

Your first visit to our clinic establishes a vital foundation for our relationship with you. Our team of distinguished and Ivy League trained physicians strive to provide the highest level of care for all of your pain vein, and wellness concerns.

To expedite your visit, we encourage you to fill out your patient forms. Completing your patient forms allows us to provide the best possible care during your time with us. These forms will be sent to you via email or mail after your appointment has been confirmed and scheduled.

We also encourage patients to familiarize with some of the HIPPA notice of privacy practices as well as other acknowledgment forms at MVM Health – Pain, Vein and Wellness. You don’t have to live with your current condition. You can request an appointment on our website or by calling our office at (570) 445-2200.

We encourage all patients to bring the following to their first office visit:

  • Insurance card(s) and related information
  • Referral documents
  • List of current medications
  • Co-payment, if applicable
  • Completed intake forms
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Recupere su comodidad y confianza: ¡mejore la salud de sus venas hoy mismo!

Encuentre un alivio duradero para las molestias causadas por afecciones venosas. Hable hoy mismo con nuestros especialistas para lograr unas piernas más sanas y atractivas.

    ¿Está listo para comenzar su evaluación gratuita de las venas?

    Sí, estoy listo.

    ¿Cuál de las siguientes opciones describe mejor la condición de sus piernas?

    Venas abultadas o retorcidas visibles en las piernas (varices)Pequeñas venas rojas, azules o moradas visibles en la piel (arañas vasculares)Sin problemas venosos notables ni síntomas visibles.Heridas, llagas o úlceras en la piel de las piernas

    ¿Experimenta algún síntoma en las piernas, los tobillos o los pies?

    Dolor (sensación dolorosa o calambres)Pesadez / CansancioSensaciones de ardor u hormigueoHinchazónZonas sensibles alrededor de las venasLlagas o úlceras cutáneas cerca del tobillo


    Si usted es candidato para un tratamiento de venas, ¿qué tan preparado está?

    Estoy listo.No estoy seguro. Tengo algunas preguntas.No quiero ayuda para mi problema de venas.


    Seguro (¿No puedes encontrar el plan? Selecciona otra)

    Nombre de la aseguradora


    Nombre de pila *

    Apellido *

    Teléfono *

    Correo electrónico *

    Restore Your Comfort and Confidence: Improve Your Vein Health Today!

    Find lasting relief from uncomfortable vein conditions. Speak with our specialists today to achieve healthier, better-looking legs.

      Are you ready to begin your free vein evaluation?

      Yes, I'm Ready

      Which of the following best describes the condition of her legs?

      Bulging or twisted veins visible on the legs (Varicose Veins)Small red, blue, or purple veins visible on the skin (Spider Veins)No noticeable vein issues or visible symptomsSkin wounds, sores, or ulcers on the legs

      Are you experiencing any symptoms in legs, ankles, or feet?

      Pain (painful sensation or cramps)Heaviness/TirednessBurning or tingling sensationsSwellingSensitive areas around the veinsSkin sores or ulcers near the ankle


      If you are a candidate for vein treatment how ready are you?

      I'm ReadyI'm not sure. I have some questions.I don't want help for my vein problem.


      Insurance (can’t find plan? select other)

      Insurance Name


      First Name *

      Last Name *

      Phone *

      Email *