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Are you dealing with Uterine Fibroids? Ask us about our newest treatment option to find relief fast!
Renew Aesthetics
|
Ozark Regional Vein & Artery Center
|
The Edge
479.777.8014
Schedule My Consultation
Am I a Candidate?
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About
Vein Care
Artery Care
Vascular Imaging
Contact
Resource Center
Meet Our Team
Our Expertise
Our Story
FAQs
Back
Vein Disorders
What are Varicose Veins?
What are Spider Veins?
Vein Treatments
Varicose Vein Treatments
ClosureFastâ„¢
Varithena®
VenaCure EVLTâ„¢
Venasealâ„¢
Ambulatory Phlebectomy
Sclerotherapy
All Treatments
Spider Vein Treatments
Sclerotherapy
Excel® V
All Treatments
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Arterial Disorders
What is Arterial Disease?
Aneurysms & Occlusive Disease
Carotid Artery Disease
May-Thurner Syndrome
Peripheral Artery Disease (PAD)
Arterial Treatments
Angioplasty and Stenting
Arterial Atherectomy
Deep Venous Stenting
Limb Salvage
Mediport Procedure
Uterine Fibroid Embolization
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Patient Forms
Arterial Patient Forms
Vein Patient Forms
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News (Blog)
Products
Make A Payment
Job Opportunities
479.777.8014
Schedule My Consultation
Am I a Candidate?
Renew Aesthetics
|
Ozark Regional Vein & Artery Center
|
The Edge
479.777.8014
Schedule My Consultation
Am I a Candidate?
About
Meet Our Team
Our Expertise
Our Story
FAQs
Vein Care
Vein Disorders
What are Varicose Veins?
What are Spider Veins?
Vein Treatments
Varicose Vein Treatments
ClosureFastâ„¢
Varithena®
VenaCure EVLTâ„¢
Venasealâ„¢
Ambulatory Phlebectomy
Sclerotherapy
All Treatments
Spider Vein Treatments
Sclerotherapy
Excel® V
All Treatments
Artery Care
Arterial Disorders
What is Arterial Disease?
Aneurysms & Occlusive Disease
Carotid Artery Disease
May-Thurner Syndrome
Peripheral Artery Disease (PAD)
Arterial Treatments
Angioplasty and Stenting
Arterial Atherectomy
Deep Venous Stenting
Limb Salvage
Mediport Procedure
Uterine Fibroid Embolization
Vascular Imaging
Contact
Resource Center
Patient Forms
Arterial Patient Forms
Vein Patient Forms
Events
News (Blog)
Products
Make A Payment
Job Opportunities
Back
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Welcome to the Ozark Regional Vein & Artery Center. What is your name?
Name
First
Nice to meet you
. We’re glad you’re here!
Are you filling this questionnaire out for yourself or a loved one?
Are you filling this questionnaire out for yourself or a loved one?
Myself
A Loved One
If you're filling this out on behalf of someone else, have their information readily available.
How old are you?
Enter your age
How old is the patient?
Enter their age
We’re going to ask you a few questions to help identify your vascular health concerns. Don’t worry, this should only take 5 minutes.
We’re going to ask you a few questions to help identify your loved one’s vascular health concerns. Don’t worry, this should only take 5 minutes.
Are you experiencing recurring leg pain, cramps, or muscle soreness that have worsened over time?
Are you experiencing recurring leg pain, cramps, or muscle soreness that have worsened over time?
Yes
No
Are they experiencing recurring leg pain, cramps, or muscle soreness that have worsened over time?
Are they experiencing recurring leg pain, cramps, or muscle soreness that have worsened over time?
Yes
No
When do you usually experience this physical discomfort? Select all that apply.
When do you usually experience this physical discomfort? Select all that apply.
When I am standing
When I am sedentary
When I am physically active
After I am physically active
When I lay down
When do they usually experience this physical discomfort? Select all that apply.
When do they usually experience this physical discomfort? Select all that apply.
When they stand
When they are sedentary
When they are physically active
After they are physically active
When they lay down
How would you rate your pain on a scale of 1-10?
How would you rate your pain on a scale of 1-10?
1
2
3
4
5
6
7
8
9
10
How would they rate their pain on a scale of 1-10?
How would they rate their pain on a scale of 1-10?
1
2
3
4
5
6
7
8
9
10
Do you have a family history of vascular disease or blood clots?
Do you have a family history of vascular disease or blood clots?
Yes
No
I’m not sure
Does their have a family history of vascular disease or blood clots?
Does their have a family history of vascular disease or blood clots?
Yes
No
I’m not sure
Have you received any prior vein or arterial treatments?
Have you received any prior vein or arterial treatments?
Yes
No
Have they received any prior vein or arterial treatments?
Have they received any prior vein or arterial treatments?
Yes
No
Do you currently take any medications for cholesterol or blood pressure?
Do you currently take any medications for cholesterol or blood pressure?
Yes
No
Do they currently take any medications for cholesterol or blood pressure?
Do they currently take any medications for cholesterol or blood pressure?
Yes
No
Are you experiencing any of these symptoms? Select all that apply.
Are you experiencing any of these symptoms? Select all that apply.
Spider Veins
Varicose Veins
Limb Swelling
Limb Hair Loss
Shiny Skin
Open Sores on Limbs
Ankle Skin Discoloration
Gangrene of Limb Tissue
None of the Listed
Are they experiencing any of these symptoms? Select all that apply.
Are they experiencing any of these symptoms? Select all that apply.
Spider Veins
Varicose Veins
Limb Swelling
Limb Hair Loss
Shiny Skin
Open Sores on Limbs
Ankle Skin Discoloration
Gangrene of Limb Tissue
None of the Listed
Final question: Will you be covering all or part of your treatment with insurance/Medicare?
Final question: Will you be covering all or part of your treatment with insurance/Medicare?
Yes
No
N/A
Final question: Will they be covering all or part of their treatment with insurance/Medicare?
Final question: Will they be covering all or part of their treatment with insurance/Medicare?
Yes
No
N/A
Alrighty, almost done! Now we just need to know how to reach you.
Alrighty, almost done! Now we just need to know how to reach them.
Phone
*
Email
*
If you have any other additional necessary comments, please leave them here!
If you have any other additional necessary comments, please leave them here!
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