About
About Vascular Tyler
Meet Our Doctors
Testimonials
Services
Services Overview
The Vein Clinic
Vascular Specialists
Robotic Surgery
Limb Preservation Program
Vascular Ultrasound Lab
Conditions
Treatments
Resources
Pre-Op Instructions
Discharge Instructions
FAQs
Contact
Free Vein Screening
903.533.8702
Free Vein Screening
Contact Info
Name
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Email
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Phone
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Questionaire
What is your age?
*
18-29
30-49
50-69
70+
Gender?
*
Male
Female
Other
Have you been experiencing any leg cramps or leg pain?
*
No
Occasionally
Daily
Have you been experiencing any swelling in your legs or ankles?
*
No
Occasionally
Daily
Which of the following conditions apply to you? Please check all that apply.
Diabetes
High Blood Pressure
High Cholesterol
Heart Disease
Smoker
Family History of Vein Disease
None
Do you have spider veins?
*
Yes
No
Do you have varicose veins?
*
Yes
No
You may upload a photo of your leg or area of concern here:
Is there any additional information you'd like to share with us?
Online Screening Consent
*
I understand that this is a preliminary online screening only for vein disease and does not constitute a complete or definitive diagnosis and does not include an in-office consultation. Information gathered in this screening is strictly confidential and is being collected for review and preliminary determination of the likelihood of vein disease existing in said participant. I hereby release the screening physician and all other health care providers from all responsibility in connection with this online screening process.
I agree
Opt In
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I agree that my mobile phone number may be used for communication via SMS/Text Messaging. Contact information will NOT be shared, sold or otherwise used by parties other than Vascular Tyler.
I agree
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