(850) 479-4223

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Coastal Vein Institute

(850) 479-4223

For Patients
For Physicians
- Physician Referral Form
Coastal Vein Institute

Providers
Services
Aesthetics
Resources
Locations
Request an Appointment

Providers
Services
Aesthetics
Resources
Locations
Request an Appointment

Providers
Services
Aesthetics
Resources
Locations
Request an Appointment

Online Vein ScreeningInsightMG2023-10-05T21:38:15+00:00

Online Vein Screening

Welcome to MyVeinScreening.com. You are taking the first step to healthier feeling and looking legs through a confidential online screening – all in the convenience and privacy of your home. By answering a few simple questions and uploading your photo(s), a board certified vascular specialist will review and make an evaluation of your venous concerns. If a formal vein consultation is recommended, you will be notified and given the information necessary to make an informed decision about which treatment option, if any, is right for you. Let’s get started!

Name(Required)

First Last

Phone(Required)

Email(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

What is your main concern?(Required)

Do you experience?

varicose veins

swelling

achiness

pain

heaviness

leg cramps

restless legs

numbness or tingling in feet

skin rash or discolored skin

ulceration or leg wound

inflammation

bleeding from spider veins

bleeding from varicose veins

superficial clots in varicose veins

Which of the following improve your symptoms?

elevation

rest

compression hose

analgesics/anti-inflammatories

diurectics or fluid pills

walking

at the beginning of the day

Which of the following worsen your symptoms?

sitting

standing

working

pregnancy

menstrual cycle

lying down

walking

at the end of the day

at the beginning of the day

Which of the following treatments have you had?

compression hose

anti-inflammatories

analgesics

injection sclerotherapy

diuretics (fluid pills)

nothing as of this presentation

endovenous ablation (laser or radio frequency)

Which statement most accurately describes how your legs feel?

legs are improved by the morning and gradually become more painful

achy and fatigued as the day progresses

legs hurt more when I walk and are relieved when I sit down or stop walking and pain returns when I walk about the same distance again

legs hurt or ache more when sitting for long periods like on a car ride or plane ride

legs hurt or ache more when standing stationary for long periods of time

Does anyone in your immediate or extended family have swollen legs, varicose veins or diffuse spider veins?

If you like to upload photos, please so do here:

Max. file size: 300 MB.

How did you hear about myveinscreening.com?

Tell Us More:

If you would like to refer a friend or family member, please enter their information below.

Name

First Last

Phone

Accept Terms & Conditions To Proceed(Required)

I agree

I hereby release the screening physician and health care professionals from all responsibility in connection with this screening process. I understand that this is a limited screening for venous disease and does not constitute a formal medical exam or complete diagnosis.

Coastal Vein Institute physicians and health care professionals agree that no one may use or share your screening results for any purpose except for screening for venous disease. Information gathered in this screening is strictly confidential, HIPAA compliant, and is being collected for review and evaluation for the likelihood of venous insufficiency in you, the participant.

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