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Sclerotherapy Follow Up.

Please fill out the following sclerotherapy follow-up form.

We look forward to seeing you after sclerotherapy to answer your questions and discuss what should come next.

Sclerotherapy Follow Up

  • MM slash DD slash YYYY
  • MM slash DD slash YYYY

  • Post Areas of Concern Diagram Here (Optional)

  • Accepted file types: jpg, jpeg, png, gif.

Area(s) of Concern

If you like, you can download the leg diagram form below and use it in one of the three ways.

1. Mark your areas of concern with the application you used to open it, save and download it into the form as .pdf or Word (.docx) file.

2. Print it out, mark it, then scan or photograph it and upload the image to the form.

3. Same as choice 2, except just bring it with you at the time of your appointment.

 

Click Image Below to Download Diagram
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