Online Consultation Varicose Veins - Alia Clinic Cosmetic Surgery

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Online Consultation - Veins

Find out an accurate costing of a procedure conveniently and quickly.
Ask any specific questions that you may have about Alia Clinic's varicose vein treatments.
As part of the consultation process, plese feel free to send a seperate email ( to Consult at Alia Clinic )with one or two photos as attachments. Many people now do this and it does help give a more accurate reply.( Please keep the photos to less than 100Kb)

Use this form to help you get the most out of your consultation. Please fill in the fields below.

Alternatively, you may submit the information directly to the clinic by simply printing the form and faxing it to (02)99061900.

* essential

Personal Details
Name	*
Age	*
Sex	*
Address for Correspondence
Email Address	* Please enter this carefully to ensure an accurately addressed reply.
Phone Number

Varicose Veins and Facial Veins Only

What procedures are you most interested in? *

	Varicose Veins Treatment		Facial Veins
	Other

Height (cms)

Weight (kg)

List any health problems

List any medications you are currently taking

Please list known allergies

(optional)

Do the veins affect one or both legs?

What symptoms do they give you? ( pain, aching, dragging, heaviness etc. )

Have you had varicose vein surgery in the past?

Have you had varicose vein injection treatments in the past?

Are the largest veins wider than 2mm?

Please enter any questions or comments.

Please give me information on the approximate costing of the procedure.

Optional information
Do you find before and after photos helpful on this website
Would you prefer to see fewer or more before and after photos on the web site.
Please enter any comments you have on the web site
How did you get to this site?
Where have you seen the clinic's promotions
Which search engine do you use the most

Optional photos - Please browse and add your relevant photos (jpg or jpeg files).If do you add photos, it will take longer to send this form. After you have added your photos, press the "Submit Enquiry" button, then wait for our reply page to ensure your form details and photos have been sent.
Photo attachment 1	(maximum size 100KB per image)
Photo attachment 2	(maximum size 100KB per image)

If you have any problems in the transmission of this form, please forward a seperate email to aliaclinic@gmail.com