Online Vein Screening

eVein Screening
Welcome to Vein Specialists' latest effort at making your vein evaluation more accessible. Our newly designed eVein screening allows you to confidentially submit your completed questionnaire and photos directly over the internet to Dr. Magnant. He will then review your questionaire responses and photos and offer his feedback on whether or not you should consider a formal vein evaluation. If you find this electronic format convenient and have family or friends who you think might appreciate this opportunity we hope you will forward the link to them as well.

First Name
Last Name
Email
Phone
Enter Your City
Enter Your Zip Code
Date Of Birth
MM
DD
YYYY
Name Of Insurance (If Applicable)
What Is your main concern?
Do you experience
** For multiple selections on PC, hold down SHIFT & Select (with mouse) all options desired
Which of the following improve your symptoms?
** For multiple selections on PC, hold down SHIFT & Select (with mouse) all options desired
Which of the following worsen your symptoms?
** For multiple selections on PC, hold down SHIFT & Select (with mouse) all options desired
Which of the following treatments have you had?
** For multiple selections on PC, hold down SHIFT & Select (with mouse) all options desired
Which statement most accurately describes how your legs feel?
** For multiple selections on PC, hold down SHIFT & Select (with mouse) all options desired
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
How did you arrive at the screening?
If other source, please explain
Accept Terms & Conditions To Proceed*
- I agree
I hereby release the screening physician and all other health care volunteers from all responsibility in connection with this screening process. I understand that this is just a screening for venous disease and does not constitute a complete or definitive diagnosis. No one may use my screening results for any purpose except for inclusion in a statistical study, without reference to or publication of any personal identifying information including name, address, phone number and email. Information gathered in this screening is strictly confidential and is being collected for review and preliminary determination of the likelihood of venous insufficiency existing in said participant.
Name
This field is for validation purposes and should be left unchanged.

* Please make sure every question that is required with a red asterik is answered, if not you will not be able to proceed in submitting your e-vein screening.