VIC Self-Referral Form

VIC Self-Referral Form

*All indicated fields must be completed.

Your First Name*

Your Last Name*

Your Birth Date*

Have you been seen at VIC before?

Please check if you've received care from a VIC provider in the past.

What vascular issues or concerns are you experiencing?

Do you have a preferred VIC location?

We'll do our best to get you scheduled at your preferred location.

Depending on availability, you may be offered an earlier appointment at another location.

Insurance Card Upload - FRONT & BACK*

This complete, accurate information will allow us to process your request quickly.

If you are having difficulty uploading your card, please call 423-602-2750 to speak with a New Patient Coordinator.

Drag and drop files here or

Your Phone Number*

VIC will use your phone for voice calls only. We won't text you.

Phone

Email Authorization

OPTIONAL - By checking this box you agree to allow VIC staff to contact you, as a new patient, using your personal email.

Email communication may place private health information you include in the message at risk of disclosure. If you prefer to communicate by phone until you can join VIC's patient portal, please select "No".

Select

Your Email Address

You've authorized us to establish you as a VIC patient through your personal email.

Please enter your personal email here.

Privacy Notice|Report Abuse

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.