Free Vein Screening Request Form The free vein screenings are held at our office located at 6408 Papermill Drive in Knoxville. The screening includes a visual assessment with our Vein RN. An Ultrasound exam is not included. If a diagnostic ultrasound is recommended, a separate appointment will be made. The ultrasound exam will be billed to your insurance. Questions? Call our office at (865) 588-8229. Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Phone*Best time to reach you by phone:MorningMiddayAfternoonHow did you learn about the free vein screening?Online searchNewspaper adTV commercialEmailFacebookOnline adOtherDo you have either of these vein issues?* "Spider" veins "Ropey" or twisted veins Swollen legs Leg pain Do you have cramping, burning or numbness in your legs or feet?* Yes No Do you have discoloration or hard to heal sores on your lower legs?* Yes No Have you had previous treatments or procedures for vein problems?* Yes No If yes, have you been treated by a Premier Vein Clinic physician? If so, which one?Additional Comments/Questions...NameThis field is for validation purposes and should be left unchanged.
