To schedule your initial consultation for varicose veins or spider veins, please call our office or fill out our online form below. Our staff will help determine what type of consultation you may need.If you have any questions, feel free to call us at 585.339.2080 or email us at TheVeinInstitute@rochrad.com.

Patient Information

1. First Name(required)
2. Last Name(required)
3. Date of Birth (mm/dd/yyyy)(required)
4. Address
5. City
6. State
7. Zip/Postal Code
8. Phone(required)
9. Alternate Phone
10. E-Mail Address(valid email required)
11. Please Contact Me By (Check all that Apply)
12. phone alternate phone e-mail
13. Referring Physician Name
14. Request Completed By

Appointment Information

1. Exam Requested
2. Mammogram DEXA Scan Ultrasound CT Scan Other
3. If other, please specify
4. Reason for Exam
5. Preferred Date (mm/dd/yyyy)(required)
6. Preferred Time(required)
7. Special Instructions

Terms of Use

1. Terms of Use By agreeing to the terms of use for online forms, you will enter a secure area of our site. Rochester Radiology and RDI will be held harmless should your electronic message not be transmitted due to technical problems. Rochester Radiology and RDI are HIPAA-compliant. Individually identifiable information is encrypted and your message will not be forwarded to other parties outside of our organization. The information will be used only by Rochester Radiology and RDI. Your request will be processed within 24 hours during regular business hours, Monday–Friday, 8 a.m.–5 p.m. If you do not hear from us by phone or e-mail to confirm your request, please call us at 585.336.5000. Please note You must accept the terms of use in order to process your request(s) online.
2. I agree to the terms and conditions
3. N/A

 

cforms contact form by delicious:days