Complimentary Vein Screening

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Treating Varicose Veins

Before & After Photos

Complimentary Screening

First Name:		*

Last Name:		*

Address 1:		*

Address 2:

City:		*

State:		*

ZIP:		*

Phone:		*

Fax:

E-mail:		*

Request Appointment:		Yes No

Questions/Comments:

How did you hear about us?


		* denotes required field

Family History:

Have you previously been diagnosed with venous reflux or venous insufficiency?

Yes No

Do you have varicose veins?
(Varicose veins are large, blue, bulging veins as opposed to spider veins, which are small, thin veins that lay close to the skin surface.)

Yes No

Do you experience any of the following symptoms in your legs or ankles?

- Leg pain, aching or cramping
- Burning or itching of the skin
- Leg or ankle swelling
- "Heavy" feeling in legs
- Skin discolorations or texture changes
- Open wounds or sores

Yes No

Has anyone in your blood related family been diagnosed with varicose veins?

Yes No

Has anyone in your blood related family had vein stripping?

Yes No

Do you have health insurance?


Yes No	Insurance Company: