Name
*
First Name
Last Name
Email
*
Date of Birth
*
-
Month
-
Day
Year
Zip Code
*
Phone Number
*
Choose your preferred clinic location
*
Please Select
Sioux City, IA
Sioux Center, IA
Aurora, IL
Fargo, ND
Eden Prairie, MN
Burnsville, MN
Plymouth, MN
St. Paul, MN
White Bear Lake, MN
Woodbury, MN
Sioux Falls, SD
Watertown, SD
Lancaster, PA
Reading, PA
Lebanon, PA
How did you hear about us?
*
Please Select
Doctor Referral
Web Search
Google Ads
TV Commercial
Magazine
Drove by Location/Location Signage
Walk-in
Radio / Streaming Radio (Spotify, Sirius XM, etc)
Billboard
Word of Mouth/Friend
Previously Seen Patient
Facebook/Instagram
Please list the doctor and/or facility that referred you (if any, or N/A).
What are your symptoms?
*
Ankle Leg Swelling
Eczema
Itching / Burning
Leg Aching
Leg Heaviness
Leg Ulcerations
Muscle Cramps (Charlie Horses)
Restless Legs
Skin Discoloration
Spider Veins
Varicose Veins
Which language do you prefer?
*
Please Select
English
Spanish
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