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