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call 937.281.0200 or Request Online
Midwest Vein & Laser is dedicated to providing patients with venous disease the highest quality of care using state of the art equipment to achieve excellent results.
1. Download the one of the patient forms above.
2. Fill it out (the forms allow you to type directly into the form).
3. Save the patient form to your computer after you've completed it. (Name it something you'll remember and don't use spaces).
4. Once you've completed 1-3 above, click browse on the form below, find the file you just saved on your computer and click "open" to attach it (or double click the file). Make sure you also have included your name and email address in the form below and then click "send".
File can take several minutes to upload so please be patient. Do not hit "send" multiple times, that will just slow the sending process down. You should see a success message once your file has been sent (2-5 minutes).