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    PLEASE CHECK ANY OF THE FOLLOWING VENOUS DISEASE SIGNS/SYMPTOMS THAT APPLY TO YOU:

    Both Legs

    Left Leg

    Right Leg

    Both Legs

    Left Leg

    Right Leg

    Both Legs

    Left Leg

    Right Leg

    Both Legs

    Left Leg

    Right Leg

    Both Legs

    Left Leg

    Right Leg

    ASSOCIATED WITH:

    Both Legs

    Left Leg

    Right Leg

    Both Legs

    Left Leg

    Right Leg

    Both Legs

    Left Leg

    Right Leg

    Both Legs

    Left Leg

    Right Leg

    Both Legs

    Left Leg

    Right Leg

    Both Legs

    Left Leg

    Right Leg

    Both Legs

    Left Leg

    Right Leg

    How long have you had these symptoms?

    Are the symptoms getting worse?

    Yes Yes

    No No

    Have you ever had any of the following treatments for your veins? (Check all that apply)

    Injections

    Stripping

    Ligation

    Laser Closure EVLT

    RF Closure

    Laser for Spider Vains

    Please describe, in as much detail as possible, the conditions you hope to improve at Ciao Bella Vein Clinic. The more specific you are, the more information we will be able to provide about appropriate treatments:

    Additional Questions, Comments, or Concerns: (optional)

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      Locations

      Chandler
      2310 W. Ray Rd.
      Chandler, AZ 85244
      480.686.8121
      Scottsdale
      22455 N. Miller Rd. B100
      Scottsdale, AZ 85255
      480.686.8121

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      9am-5pm
      Friday
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