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: