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Elite Vein Clinic - Digital Referral Form
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Referring Organization
*
Your answer
Referring Physician
*
Your answer
Patient Name
*
Your answer
Patient Date of Birth
*
MM
/
DD
/
YYYY
Patient Phone Number
*
Your answer
Issues? (Check all that apply)
*
Painful or a aching legs
Heaviness of the legs
Fatigue/Tiredness
Ankle/Leg Swelling
Throbbing Legs
Burning or itching of the skin
Cramping at night
Restless legs
Varicose Veins
Skin changes or ulcers of the legs
Other:
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