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Vein Questionnaire

Vein Questionnaire

Consultation Questionnaire

Please answer the following questions. If you answered yes to any of these questions below, you may be a candidate for a vein treatment consultation.

Have you ever experienced pain, discomfort, cramping or aching in your legs? *

Yes

No

Have you ever experienced restless legs? *

Yes

No

Do you have varicose or spider veins in your legs? *

Yes

No

Do you have swelling in your legs? *

Yes

No

Do you have change in skin color in your legs? *

Yes

No

In the past or currently do you stand or sit for long periods of time? *

Yes

No

In the past or currently have you performed frequent heavy lifting? *

Yes

No

Would you like to see a vein specialist to discuss any issues you are having? *

Yes

No

YES! I would like more information or to schedule a consult, please contact me.

Contact information

Name:

Please enter a valid name

Phone

Please enter your phone number

Email

Please enter a valid email

How did you hear about us?

Doctor

Friend/Family

Flyer/Brochure

Social Media

Google Search

Website

Ad

Radio

TV

Seminar

Other

If other please specify:

Thank you for submitting your vein candidate form

Someone from our office will contact you within a week. If you feel you need to be seen sooner, please give our office a call at 716-710-8266

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