New patient

New Patient Appointment Request Form


Before filling this form please contact your insurance to verify we are a contracted provider. 

New patients who  would like to make an appointment may fill this form. We will screen the request and will send you an email with a link to the patient portal called "yourhealthfile".
The email you will receive is from our EMR, called nextgen (HFalerts@nextgen.com). 
This form is intended for new patients only who suffer from chronic symptomatic varicose veins or have been diagnosed with chronic venous insufficiency. If you feel your concerns are mainly cosmetic please be aware that we only treat medically necessary cases, and we do not perform cosmetic treatments

Existing patients should not use this form, and can either use their patient portal account or call the office to make an appointment. This form is not for urgent messages. If you do not receive an email or a phone call within 5 business days please call the office at 480-247-8662. 

If you feel you have an urgent medical issue please seek urgent medical care.

First Name: *
Last Name: *
Date of birth: *
Gender: *
Address Street 1: *
Address Street 2:
City: *
Zip Code: * (5 digits)
State: *
Daytime Phone: *
Evening Phone:
Health Insurance Plan: *
Email: *
I confirm I am a new patient. *
I am new patient, I read and understood that this form is not for urgent messages or medical advice, and due to possible flaws in informatic technology SCOVAS declines any responsibility for missed or unanswered forms. I do not have any acute condition and I will not submit this form to discuss acute symptoms: *

I understand that by submitting this form I hereby declare I AM A NEW PATIENT trying to make a new non-urgent appointment, and I agree on receiving an email with a link to a website. I believe I have varicose veins and I have one or more of the following -chronic only- symptoms: leg swelling,  pain, cramps, chronic numbness, chronic tingling, itching, restless legs, chronic ulcers, chronic heaviness, past bleeding vein, past blood clots, skin dark brown discoloration, tired legs.