Free Virtual Vein Screening

2 - Do you experience any of the following signs and symptoms in your legs or ankles?
Check all that apply
- Leg pain, aching or cramping
- "Heavy" feeling in legs
- Burning or itching of the skin
- Visible varicose or spider veins
- Leg or ankle swelling, especially at the end of the day
- Skin discoloration or texture changes, such as above the inner ankle
- Open wounds or sores, such as above the inner ankle
- Restless Leg Syndrome
Are you currently wearing compression stockings? (Compression therapy is required for a period of three months prior to further intervention. If you’ve already been wearing compression stockings, the timeline of your treatment plan may be reduced.)

3 - Patient Risk Factors
Has anyone in your family suffered from varicose veins or been diagnosed with chronic venous insufficiency or venous reflux?
Have you had any treatments or procedures for vein conditions?
If yes, what treatments or procedures have you had? (This will help us determine the best treatment options for you.)
Do you smoke?
Have you ever been pregnant?
Do you stand for long periods of time, such as at work?
Do you frequently engage in heavy lifting?

Choose Photos

If possible, please upload a photo or two of your symptomatic leg veins. This will help our doctors provide feedback. If you are unable to upload images, examples to choose from can be found in the next step.
Image 1
Accepted file types: jpg, jpeg, gif, png, Max. file size: 128 MB.
Image 2
Accepted file types: jpg, jpeg, gif, png, Max. file size: 128 MB.

5 - Visible Symptoms

If you aren’t able to upload a photo, please select the pictures that best represent your symptomatic leg veins. Please select up to three images that best represent your symptomatic veins.
Check all that apply
- Varicose Veins 1
- Varicose Veins 2
- Spider Veins 1
- Spider Veins 2
- Leg Swelling
- Leg Ulcer
- Foot Ankle Swelling
6 - Further Description
Please describe your symptomatic leg veins in more detail.

7 - Contact Preference

How would you like one of our vascular surgeons to contact you with your results?
Contact Method*
- Email: One of our vascular surgeons will review this form and email you within 48 hours.
- Phone: A patient coordinator will contact you by phone within 48 hours to set up a consultation.
- Text: One of our vascular surgeons will review this form, and a patient coordinator will text you within 48 hours.
- FaceTime on an iPhone: A patient coordinator will contact you to set up a free FaceTime consultation with one of our vascular surgeons.

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