*Your Name
*Street Address
*City, State & Zip Code
*Telephone Number
*E-mail Address

How did you hear about us?
Physician Internet Friend Another Patient Newspaper Radio Other
If referred by a physician, name of physician:

Do you have varicose veins? Yes No
Do you have spider veins? Yes No
Would you like to discuss treatment? Yes No
Do you have medical insurance? Yes No
                (If "yes" name of insurance:)
Would you like us to contact you for an appointment? Yes No
Other Questions or Comments:

Legal Mumbo Jumbo:  By submitting this inquiry, I agree that (1)  Blue Ridge Vein Care, Inc. is not engaged in business in any other jurisdiction than Bedford, Virginia, and has not purposely availed itself of the laws or benefit of any other jurisdiction, that (2) Blue Ridge Vein Care, Inc. and its physician(s) are not engaged in the practice of medicine in any other jurisdiction than Virginia.