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(AFUADOMI Form HI Website, Rev.10.31.2012) AUTHORIZATION FOR USE AND DISCLOSURE OF MEDICAL INFORMATION Patient Name: Chart #: (Last, First, MI) Date of Birth: Phone: Social Security #: (Optional)

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1. Start by visiting the website www.hogueveincom.
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5. Complete any additional fields or forms that are necessary for registration.
6. Double-check all the information you have entered to ensure accuracy.
7. Review and agree to any terms and conditions or privacy policies.
8. Submit your registration form by clicking the "Submit" or "Join" button.
9. You may receive a confirmation email or be directed to a confirmation page upon successful registration.
10. Log in to your newly created account using your username and password to start using www.hogueveincom.

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