Have you ever been diagnosed with varicose veins? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Have you had treatment for varicose veins? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Do you have a family history of varicose veins/venous reflux? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Do you have ankle swelling with prolonged standing/sitting or air travel? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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During pregnancy, did you have leg swelling or bulging leg veins? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Please check the boxes next to any of the following leg symptoms you experience: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Someone in our office will contact you regarding your vein assessment.
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Have you ever been diagnosed with varicose veins? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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{ binding firstError.message }
Have you had treatment for varicose veins? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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{ binding firstError.message }
Do you have a family history of varicose veins/venous reflux? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Do you have ankle swelling with prolonged standing/sitting or air travel? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
During pregnancy, did you have leg swelling or bulging leg veins? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Please check the boxes next to any of the following leg symptoms you experience: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Someone in our office will contact you regarding your vein assessment.
Full Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Phone Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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{ binding firstError.message }
Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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