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Patient Information

Clinical Information

Yes No Do you have varicose veins (visibly enlarged, bulging veins beneath the skin)?
Yes No Do you have spider veins (small, visible blood vessels in the skin)?
Yes No Do you have symptoms such as pain, swelling, heaviness, burning, itching, etc?
Left Right Which leg is symptomatic?
Yes No Are you pregnant or planning to get pregnant?
Yes No Does anything hinder your mobility (ie. crutches, cast, wheelchair)?
Yes No Have you had vein treatments/procedures in the past?
    If Yes, what kind of procedure and when did you have it done?

Preferred Locations

Preferred Date, Time and Physician

1st choice for day: 2nd choice for day :
Time preference: Physician Preference :

 

Yes No Did you see our ad on Facebook?