Home » Patient Information » Complimentary Virtual Vein ScreeningComplimentary Virtual Vein Screening 1Provide Patient Contact InformationFirst Name * Last Name * Email Address * Phone Number * Street Address City State Zip Code 2Patient Assessment QuestionsDo you experience any of the following signs and symptoms in your legs or ankles?Leg pain, aching or crampingyesnoBurning or itching of the skinyesno"Heavy" feeling in legsyesnoLeg or ankle swelling, especially at the end of the dayyesnoVisible varicose or spider veinsyesnoSkin discoloration or texture changes, such as above the inner ankleyesnoOpen wounds or sores, such as above the inner ankleyesnoRestless Leg Syndromeyesno3Patient Risk FactorsHas anyone in your blood-related family had varicose veins or been diagnosed with chronic venous insufficiency or venous reflux?yesnoHave you had any treatments or procedures for vein problems?yesnoDo you stand for long periods of time, such as at work?yesnoDo you frequently engage in heavy lifting?yesnoHave you ever been pregnant?yesno4Choose PhotosIf possible, please upload a photo that best represents your vein problem. This will help our doctor provide more accurate feedback.5Further DescriptionPlease use this space to describe your vein problems in more detail.6Contact PreferenceHow would you like our doctor to contact you with his opinion?E-Mail: One of our doctors will review this form and e-mail you as soon as possible.Phone: A patient coordinator will contact you to set up a free phone consultation with one of our doctors.Facetime on an iPhone: A patient coordinator will contact you to set up a free Facetime consultation with Dr. Garg. Your InformationPreferred Contact Method *PhoneEmail-Send Brochure-State: *ALAKASAZARCACOCTDEDCFMFLGAGUHIIDILINIAKSKYLAMEMHMDMAMIMNMSMOMTNENVNHNJNMNYNCNDMPOHOKORPWPAPRRISCSDTNTXUTVTVIVAWAWVWIWYWhat's On Your Mind?[recaptcha]* Required FieldsPlease be aware that this is a non-secure communication.back to top
