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Physician Referral Form

Thank you for sending us your patients! We specialize in the latest minimally-invasive treatment of Venous Insufficiency and its consequences including Varicose Veins, Spider Veins, Stasis Dermatitis and Venous Ulcers. Please submit the following form or call us at 313-561-2622 or download our referral form and fax us at 313-561-2774.

Patient Information

First & Last Name *
Phone Number *
Date of Birth
Insurance Provider *

Referring Physician's Information

Physician's Full Name *
Address Line 1 *
City, State, Zip Code *
Line 2
Physician's Phone*

Thanks! We have received your referral and will contact you should we have any further questions. 

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