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Patient Forms

The Patient Intake Form (.pdf) is a one-page detailed questionnaire about your family medical history, social history, past surgical history and medical history. Please bring the completed form to your appointment.

The Vein History and Medical Necessity Form (.pdf) is one-page questionnaire about your symptoms, causes of leg pain and if you have been treated for a vein disease in the past. Please bring the completed form to your appointment.

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1535 Gull Road, Suite 200, Kalamazoo, MI 49048 |
269.585.8346