Free PAD Screening

FIND OUT IF YOU'RE AT RISK FROM PERIPHERAL ARTERY DISEASE.

(1) Complete the FREE online screening below (takes less than a minute)

(2) After you complete the form, we’ll set up a time to speak with you to discuss your symptoms, insurance, and treatment options

Complete Below:

Do you experience pain in your toes or feet at night? *

Yes

Do you have aching, cramping, tingling, or pain in your legs when you walk or exercise that is relieved by rest? *

Yes

Have you noticed a change in the color of your legs? *

Yes

Do you have ulcers or sores on your feet or legs that are slow in healing? *

Yes

Do you currently smoke? Have you ever smoked? *

I currently smoke

I used to smoke

I have never smoked

Does your family have a history of diabetes? *

Yes

Do you have (check all that apply then press 'Next'):

Diabetes

Coronary Artery Disease

High Cholesterol

Previous Stroke/ TIA

High Blood Pressure

Date of birth (MM/DD/YYYY) *

We also provide you with a complimentary insurance assessment

Insurance Coverage:

Medicare

Private Insurance

HMO

PPO

Medicaid

HMO Kaizer

No Insurance/ self-pay

Which Location is Most Convenient for You? *

Which Location is Most Convenient for You?

Please confirm your contact details are correct. We will send you your results to the phone and e-mail below:

First Name *

Last Name *

Email *

Phone *

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