If you would like someone from our office to contact you, please fill out this form

Name: 

Birth Date: 

Email: 

Telephone: 

How many years have you had varicose veins? 

Do you experience any of these in your legs: 

\Pain     Aching    Heaviness    Restless Legs     Swelling

Have you had a procedure to treat varicose veins?  Yes     No

Are you taking blood thinners?  Yes     No

Have you ever had a blood clots in your veins?  Yes     No

Questions: