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Computed Tomography
Fluoroscopy
Interventional Radiology
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Vein Candidate Survey
Take the following survey to find out if you're a candidate for Varicose Vein Treatments with SJI:
Which of the following affects you?
Leg pain, aching or cramping
Burning or itching of the skin
Leg or ankle swelling, especially at end of day
“Heavy” feeling in legs
Varicose Veins
Skin discoloration or texture changes
Open wounds or sores
Restless Legs
Spider Veins
Check all that apply.
Which of the following applies to you?
Someone in my family has had varicose veins in the past.
Someone in my family has been diagnosed with chronic venous insufficiency or venous reflux.
I have undergone vein treatments in the past.
I often stand for extended periods of time.
I frequently perform heavy lifting tasks.
I have been pregnant.
Check all that apply.
Name
*
Date of Birth
*
MM slash DD slash YYYY
Phone
Email Address
*
Would you like to be contacted to schedule a consultation?
Yes, please follow up for a consultation.
No
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Please register me for your next Vein Treatment Education Seminar/Free Screening.
How did you hear about Vein Care Treatments at St. Joseph's Imaging?
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