Vascular Health Self Assessment
Find out if a consultation with a Vascular Surgeon is right for you
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Varicose Veins
Do you have varicose veins?
Yes, I have varicose veins
No
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Leg Swelling - Edema
Do you have swelling in your legs?
Yes, I have swelling in my legs
No
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Leg Discoloration
Do you have discoloration in your legs?
Yes, I have discoloration in my legs
No
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Ulcers & Non-Healing Wounds
Do you have ulcers & non-healing wounds on your legs?
Yes, I have ulcers and / or non-healing wounds on my legs
No
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Burning & Itching
Do you have burning or itching sensation in your legs?
Yes, I have burning and / or itching sensation in my legs
No
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Leg Pain & Aching Sensations
Do you have pain or aching in your legs?
Yes, I have pain and / or aching in my legs
No
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Leg Heaviness & Fatigue
Do you have fatigue or feel heaviness in your legs?
Yes, I have fatigue or feel heaviness in my legs
No
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Restless Legs
Do you have a restless sensation in your legs?
Yes, I have restless sensations in my legs
No
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Cramps & Throbbing Sensations
Do you have cramps & throbbing sensations in your legs?
Yes, I have cramps and / or throbbing sensations in my legs
No
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Continue To See Your Score
Full Name
*
First Name
Last Name
Email
*
example@example.com
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Scheduling A Consultation Is Recommended
Score: 1 out of 9
Scheduling A Consultation Is Recommended
Score: 2 out of 9
Scheduling A Consultation Is Recommended
Score: 3 out of 9
Scheduling A Consultation Is Recommended
Score: 4 out of 9
Scheduling A Consultation Is Recommended
Score: 5 out of 9
Scheduling A Consultation Is Recommended
Score: 6 out of 9
Scheduling A Consultation Is Recommended
Score: 7 out of 9
Scheduling A Consultation Is Recommended
Score: 8 out of 9
Scheduling A Consultation Is Recommended
Score: 9 out of 9
Scheduling A Consultation Is Optional
Score: 0 out of 9
Calculation
If you answered yes to any of these questions you should schedule a venous ultrasound immediately
Yes, I want to schedule a consultation
No, I do not want to schedule
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I am a
*
New Patient
Current Patient
Preferred Appointment Date and Time
Office Location
*
Massapequa Office: 6175 Sunrise Highway, Massapequa, NY 11758
Preferred Appointment Date and Time
*
Personal Information
Phone Number
*
-
Area Code
Phone Number
Date of birth
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How will you be paying?
Insured
Uninsured
How would you like to add your insurance information?
*
Take a picture of the insurance card
Add insurance information manually
Take photo of the back side of the insurance card
*
Insurance Carrier
*
Take photo of the front side of the insurance card
*
Insurance Subscriber Number
*
Attach Image Of Insurance Card
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How did you hear about us?
Google
Bing
Yelp
Social Media
Reputation/Reviews
Newspaper/Article
Dr. Recommendation
Friend or Family
Insurance
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