Contact Information
Let us know how we can get in touch following your screening.
Patient Assessment Questions
Let us know about your conditions.
Patient Risk Factors
Information that helps diagnose your condition.
Photo Upload
If you have a visible condition, photos are very helpful in screening.
Contact Info
Please note before you begin the screening, that this is a 100% free offer with no obligation to you whatsoever. The patient and / or any other person responsible for payment has a right to refuse to pay, cancel payment, or be reimbursed for payment for any other service, examination, or treatment or treatment that is performed as a result of and within 72 hours of responding to the advertisement for free, discounted fee, or reduced fee service, examination, or treatment.
Patient Assessment Questions
Leg Pain, aching or cramping
Burning or itching skin
Heavy feeling in legs
Visible varicose or spider veins
Leg or ankle swelling, especially later in 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
Risk Factors
Has anyone in your blood-related family had varicose veins?
Has anyone in your blood-related family had chronic venous insufficiency or venous reflux?
Have you had treatments or procedures for vein problems?
Do you stand for long periods, such as at work?
Do you frequently engage in heavy lifting?
Have you ever been pregnant?
Take up to three front / back photos in natural light of your condition, and then attach them here (optional).
Photo 1
Max. size: 50.0 MB
Photo 2
Max. size: 50.0 MB
Photo 3
Max. size: 50.0 MB