Sclerotherapy Intake FormSclerotherapy Intake Form First Name * Middle Name * Last Name * Date of Birth Age Cell Phone OK to text? Yes No Email Home Street Address City Zip If Groupon, number of syringes purchased: 2 Syringes 4 Syringes 0 Syringes Area(s) to be treated Name of birth control? Have you previously had Spider Vein Treatments? Yes No Were they Injections, Laser, or Both? Did you have any adverse reactions from your previous spider vein treatments? Yes NoAllergies to latex gloves? Yes NoAllergies to tape adhesives? Yes NoAllergies to Glycerine? Yes No Please list any additional allergies: Are you currently on blood thinners? Yes NoPregnant? Yes NoBreast Feeding? Yes NoAre you on birth control? Yes No Name of birth control? Do you smoke? Yes No What is your height? Inch What is your weight? Are you currently taking any Antibiotics - Tetracycline, Doxycycline, Sumycine Actisite, Achromycin, Minocycline, Clindamycin, Minocin, Dynacin, Solodyn, Ximino, Doxy Doxycin, Vibramycin, Oracea, Doryx MPC? Yes No(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? Yes NoAre you taking any Narcotics or any other substance than can impair your judgment? Yes NoHave you taken Iron within the last month? Yes NoIf 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? Yes No List all medications: Initial each bullet point after reviewing: If you do not give a 48-hour notice of appt. change, it is considered a no show and a $90 fee will be placed on your account or you will forfeit your Groupon purchase as will be decided by Anti Aging & Functional Medicine. One week prior to your appointment, you cannot take any blood thinners such as Aspirin, Advil, Aleve, Motrin, Ibuprofen, Alcohol, and all vitamins. Shave your legs the day before or day of your appointment with a brand new razor. The day of your appointment, drink a lot of water The day of your appointment, please do not wear lotion on your legs Wear loose clothing around your legs or please remember to bring a pair of shorts. No sitting (traveling) or standing for long periods of times within one week post injection Being on Birth Control can increase the risk of blood clots and Thrombophlebitis Please bring panty hose or leggings to wear after your spider vein treatment Questions, Concerns, and Additional Comments reCAPTCHA If you are human, leave this field blank. Submit
