Anti Aging & Functional Medicine

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Sclerotherapy Intake Form

Sclerotherapy Intake Form
OK to text?
If Groupon, number of syringes purchased:
Have you previously had Spider Vein Treatments?
Did you have any adverse reactions from your previous spider vein treatments?
Allergies to latex gloves?
Allergies to tape adhesives?
Allergies to Glycerine?
Are you currently on blood thinners?
Breast Feeding?
Are you on birth control?
Do you smoke?
Are you currently taking any Antibiotics - Tetracycline, Doxycycline, Sumycine Actisite, Achromycin, Minocycline, Clindamycin, Minocin, Dynacin, Solodyn, Ximino, Doxy Doxycin, Vibramycin, Oracea, Doryx MPC?
(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?
Are you taking any Narcotics or any other substance than can impair your judgment?
Have you taken Iron within the last month?
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?

Initial each bullet point after reviewing: