Ok let's get started..
Zip code
Gender
Female
Male
Do you Have Diabetes?
Yes
No
Do you have High Cholesterol?
Yes
No
Are you Over 50 years Old?
Yes
No
Does Your Family Have a History of Diabetes?
Yes
No
Do you Currently Smoke? Have you ever smoked?
Yes
Occasionally
Never
Do you have aching, cramping, tingling, or pain in your legs when you walk or exercise that is relieved by rest?
Yes
No
Do you have pain in your toes or feet at night?
Yes
No
Do you experience leg numbness, weakness or a difference in temperature in your lower leg or foot?
Yes
No
Have you noticed a change in the color of your legs?
Yes
No
Do you have ulcers or sores on your feet or legs that are slow in healing?
Yes
No
Please provide your insurance
Blue Cross Blue Shield
Florida Blue
United Health Care
Cigna
Aetna
Humana
Medicaid
Medicare
Oscar Health
Cash/Out of Pocket
Other
Provide Insurance
Please confirm your contact details are correct. We will send you your results to the e-mail below:
Full Name
*
Date of Birth
*
Phone
*
Email
*
Please Choose a preferred Clinic day
*
Choose a day
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
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Please Choose a Preferred Clinic Time
*
Please Choose Time
8:00 AM
9:00 AM
10:00 AM
11:00 AM
1:00 PM
2:00 PM
3:00 PM
4:00 PM
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