Personal Information Location and Time Insurance Thank you First Name* Last Name* Email* Confirm email* Please ensure email address is accurate as all important information regarding treatment, schedules will be sent here. Mobile Phone* Gender (optional) Male Female Date of Birth* I'm under the age of 18 years old and I confirm my parent(s) or personal representative consent my intention to have a treatment at USA Vein Clinics Zip Code* State* AR AZ CA DC FL GA IL IN MA MI NJ NY OH PA TX UT VA WA WV I have Insurance Insurance Self Pay Insurance* Please select your State above to check Insurance plans Insurance name* Member id Phone Number from the back of the Insurance Card By submitting this form you agree to our Privacy Policy. Sorry We could not determine that you are an existing patient. Please call 888.768.3467 to get an access or schedule next appointment It looks like you are already an existing patient. Please call us at 888.768.3467 to finish scheduling your appointment. OK It looks as though you are already registered. Confirm by entering the code sent to your phone on file. For further assistance, please contact us. Sms code was sent to this phone number [phone] 2FA Code No available clinics have been found! OK One moment please...
