Forms — Premier Vein and Vascular

Intake Form

Let’s get some information before your visit! This will help us get the most out of your first appointment.

Name

First Name

Last Name

Phone

(###)

###

####

Reason for visit

Medical Conditions

Please list all medical conditions and diagnoses, if none list "none"

Medications

Please list all medications, if none list "none"

Medical Information Release

Do you give permission for review of medical records ahead of your visit?

For visits related to spider vein or varicose vein visits ONLY. Please submit this form ahead of your visit!

Name

First Name

Last Name

Phone

(###)

###

####

Reason for visit

Cosmetic spider veins or bulging varicose veins?

Do you have any symptoms of leg pain, heaviness or achiness?

Have you ever had a vein procedure?

Vein procedures?

Please list any vein procedures you have had in the past. If none, leave blank

Have you ever had a blood clot?

Have you had an ultrasound to look at your leg veins within the last year?

Hormones

Are you taking any hormones such as estrogen, hormone replacement or birth control?

Medical Information Release

Do you give permission for review of medical records ahead of your visit?