Online Consultation - Vein Treatments

• 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.

Personal Details
Name	*
Age	*
Sex	Please select-- male female *
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?	Please select-- One Leg Both Legs
What symptoms do they give you? ( pain, aching, dragging, heaviness etc. )
Have you had varicose vein surgery in the past?	Please select-- Yes, I have had varicose vein surgery No, I haven't had varicose vein surgery
Have you had varicose vein injection treatments in the past?	Please select-- Yes, I have had injection treatments No, I haven't had injection treatment
Are the largest veins wider than 2mm?	Please select-- Yes, they are greater than 2mm No, they are less than 2mm
Please enter any questions or comments.
Please give me information on the approximate costing of the procedure.	Please select-- Yes No

Optional information
Do you find before and after photos helpful on this website	Please select-- Yes No
Would you prefer to see fewer or more before and after photos on the web site.	Please select-- More Less
Please enter any comments you have on the web site
How did you get to this site?	Please select-- printed advertisments yahoo google ninemsn other search engine referal other...
Where have you seen the clinic's promotions	Please select-- Yellow Pages Good Medicine 9 to 5 North Shore Times Northern District Times Hills News Wentworth Courier Sun Herald Sunday Telegraph Sydney Weekly Hills Shire Times Other...
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

For more information about choosing a doctor or deciding on a cosmetic procedure, please download a copy of the Australasian College of Cosmetic Surgery’s patient information brochure, “Things you should know”.  A copy of the ACCS Code of practice is also available by visiting the College’s website.