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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

Office hours

Monday - Thursday
9am-5pm
Friday
9am - 3pm

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