Vein Screening Consultation

Our physicians will review your questionnaire responses and photos and offer their feedback on whether or not you should consider vein treatment.

Name*

E-mail Address*

Phone Number*

What your main concern?*

Do you experience:

Which of the following improve your symptoms or when are your symptoms improved?*

Which of the following worsen your symptoms?*

Which of the following treatments have you had?*

Which statement most accurately describes how your legs feel?*

Does anyone in your immediate or extended family have swollen legs, varicose veins or diffuse spider veins?*

If you like to upload photos, please so do here:



How did you arrive at the screening?*

If other source, please explain:

Accept Terms & Conditions To Proceed *
I hereby release the screening physician and all other health care volunteers from all responsibility in connection with this screening process. I understand that this is just a screening for venous disease and does not constitute a complete or definitive diagnosis. No one may use my screening results for any purpose except for inclusion in a statistical study, without reference to or publication of any personal identifying information including name, address, phone number and email. Information gathered in this screening is strictly confidential and is being collected for review and preliminary determination of the likelihood of venous insufficiency existing in said participant.