Online Vein Screening Fill out the form below and hit “Send” to submit your information to Great Lakes Surgical. A member of our team will be in touch within 48 hours (two business days) to discuss your answers and schedule a follow up appointment if necessary. Vein Screening Signs & SymptomsDo you experience or suffer from any of the following signs or symptoms in your legs? Leg heaviness or fatigue Restless legs Itching or burning of the skin Leg or ankle swelling Leg pain, aching, cramping or throbbing Skin discoloration or texture change Open wounds, sores or venous ulcers Risk FactorsHas anyone in your blood-related family ever had varicose veins or been diagnosed with venous disease? Yes No Do you stand for prolonged periods of time? Yes No Have you ever had varicose veins? Yes No Have you ever had spider veins? Yes No Do you have any problem walking? Yes No Walking - Yes If yes, how does it affect you?Have you ever had any test(s) done on your veins? Yes No Tests - Yes If yes, what type of test and where on the leg?Have you been diagnosed with saphenous vein reflux? Yes No Contact InformationDue to the nature of medical information, you will be contacted by phone. Please make sure you provide an accurate phone number. Name First Last PhoneEmail How did you hear about our office? Internet search Social media Family/friend WLVL/Radio Union Sun & Journal Health magazine The Bee (Amherst Bee, Kenmore Bee, etc.) Other (please specify) Other General Info Call our office: 716-434-6141 GreatLakesSurgery@Yahoo.com 160 East Ave., Lockport, NY 14094 2914 Elmwood Ave., Kenmore, NY 14217 Better Health Care is Our Mission Same Day Appointments are Available. Phone: 716-434-6141 Fax: 716-434-0594 Email: GreatLakesSurgery@Yahoo.com Lockport Address: 160 East Ave. Lockport, NY 14094 Find us on Google Kenmore Address: 2914 Elmwood Ave. Kenmore, NY 14217 Find us on Google Appointments in Kenmore Office available by request Book an Appointment Today!