Free Vein Diagnostic
Please complete this form to help us understand your vein health and provide you with personalized diagnosis and treatment options. Designed for international patients.
What symptoms are you currently experiencing?
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Bulging veins
Leg heaviness or tiredness
Pain or aching
Swelling
Itching or burning
Restless legs
Skin discoloration
Previously treated veins returning
No symptoms, only cosmetic concerns
How long have you had these symptoms?
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Less than 6 months
6–12 months
1–3 years
More than 3 years
Have you been diagnosed with varicose veins or venous insufficiency before?
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Yes, officially diagnosed
Not officially, but I suspect it
No diagnosis yet
Have you had any previous vein treatments?
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No, never
Laser (EVLA / EVLT)
Radiofrequency ablation (RFA)
Sclerotherapy
Surgery (stripping/ligation)
Glue or foam treatment
Not sure
Which leg is affected?
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Right
Left
Both
How would you describe the appearance of your veins?
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Spider veins
Medium varicose veins
Large bulging varicose veins
Skin changes (darkening or thickening)
Open wound or ulcer
Do your symptoms affect your daily activities?
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Yes, significantly
Yes, moderately
Mildly
Not really
Only cosmetically bothersome
What is your main reason for seeking treatment?
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Medical reasons (pain, swelling, discomfort)
Preventing worsening
Cosmetic improvement
Combination of the above
Are you considering treatment abroad (international medical travel)?
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Yes
Possibly
No
Full Name
*
First Name
Last Name
Country of Residence
*
Email
*
example@example.com
WhatsApp Number (preferred)
*
Please enter a valid phone number.
Format: (000) 000-0000.
Upload leg photos (optional but recommended)
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