Contact us today.

We ask new patients to open, download, and print the forms below. Please complete these forms and bring them with you to your initial office visit.

Please also bring your insurance card and a government-issued photo identification card.

New Patient Medical History

Click Here to Download the New Patient Medical History Form

Patient Contact Information

Click Here to Download the Patient Contact Information Form

Release of Medical Information

Click Here to Download the Release of Medical Information Form

Patient Financial Policy

Click Here to Download the Patient Financial Policy Form

General Consent for Treatment

Click Here to Download the General Consent for Treatment Form

  • Free New Patient Consultation Call

  • An Independent Physician Owned Specialty Practice Located on the Tennova Healthcare CampusSEE MAP AND DIRECTIONS
  • Patient Testimonials

    "The staff here is excellent; you could not find a better doctor or nursing and office staff. You are always treated with the utmost respect. The nursing staff is very informative, and Dr. Daugherty is very caring and compassionate." -- D.C.

    Questions About Insurance Coverage?

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    Men Have Varicose Veins Too

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