Sclerotherapy Intake Form

    OK to text? YesNo

    If Groupon, number of syringes purchased: 2 Syringes4 Syringes0 Syringes 

    Have you previously had Spider Vein Treatments? YesNo

    Did you have any adverse reactions from your previous spider vein treatments? YesNo
    Allergies to latex gloves?YesNo
    Allergies to tape adhesives? YesNo
    Allergies to Glycerine?YesNo

    Are you currently on blood thinners? YesNo

    Pregnant? YesNo
    Breast Feeding?YesNo
    Are you on birth control? YesNo

    Do you smoke? YesNo

    What is your height?

    Are you currently taking any Antibiotics - Tetracycline, Doxycycline, Sumycine Actisite, Achromycin, Minocycline, Clindamycin, Minocin, Dynacin, Solodyn, Ximino, Doxy Doxycin, Vibramycin, Oracea, Doryx MPC? YesNo(If you are taking any of the above Antibiotics, you can’t schedule until four weeks after the prescription has ended)   
    Are you taking over the counter baby aspirin or regular aspirin? YesNo
    Are you taking any Narcotics or any other substance than can impair your judgment? YesNo
    Have you taken Iron within the last month?YesNo   If Iron is being taken, then appointment can’t be made until two weeks after patient has stopped.  
    Have you ever been diagnosed with any blood clot disorders? DVT? Pulmonary Embolism? Thrombophlebitis?YesNo

    Initial each bullet point after reviewing: