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Varicose Vein Screening Survey

ARE YOU A CANDIDATE FOR A VARICOSE VEIN SCREENING?

Please fill out this screening sheet and submit.

We will contact you if you are a candidate for a consultation to discuss your options.

Form

    Name*
    Date of Birth*
    Phone Number*
    Email*

    Please check any of the following symptoms you experience:

    Leg pain, aching or crampingBurning or itching of the skinLeg or ankle swelling, especially at end of day“Heavy” feeling in legsLeg fatigueSkin discoloration or texture changesOpen wounds or soresRestless legs

    How would you like us to contact you?

    EmailPhone

    If you checked 3 or more of the above, you are eligible for a consult to discuss vein disease and treatment options.

    *Please note this is offered at Williamsville  location only*

    Thank you for your Participation

    CALL FOR AN APPOINTMENT ON OUR DIRECT LINE AT (716) 929-9484

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