PAD Screening Appointment Request Form | Premier Surgical Associates

PAD Screening Appointment Request

A non-invasive screening test can help diagnosis Peripheral Arterial Disease or PAD. If you are in the high risk category, the test is covered by most insurance plans.

Name*
First Last
Address
Street Address Address Line 2 City State ZIP Code
Email*
Phone*
Best Time to Call
Please indicate if you have any of the following Peripheral Arterial Disease (PAD) risk factors:*
- I have leg cramps when I walk, climb steps or exercise
- I have sores on my feet or legs that won’t heal
- I have diabetes
- I smoke cigarettes
- I have high cholesterol
- I have high blood pressure
- I am overweight
Preferred Appointment Date*
Date Format: MM slash DD slash YYYY
Preferred Appointment Time of Day*
How did you hear about Premier Surgical Vascular Services?*
Comments/Questions
Comments
This field is for validation purposes and should be left unchanged.

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PAD Screening Appointment Request

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