Do you believe you have varicose veins?
(Varicose veins are large bulging veins with a blue appearance.)
Yes No

Do you believe you have spider veins?
(Spider veins are small, thin veins near the surface of the skin.)
Yes No

Do you experience any of the following symptoms?
Leg pain, aching or cramping
Burning or itching
Leg or ankle swelling
Heavy feeling in legs
Open wounds or sores
Skin discolorations or texture changes

Has anyone in your family been diagnosed with varicose veins or spider veins?
Yes No

Insurance Information: (optional)
Please send us the following insurance information so that we can verify your coverage prior to your appointment.