Schedule a FREE CONSULTATION

Ask a Question / Request a Free Consultation

Midwest Vein & Laser is dedicated to providing our patients with the best possible care and personal attention. We consult with every potential patient individually, at no charge, so we can tailor treatment to their specific needs.

 

In-person consultations are done at our Dayton, Ohio office location. Please use the form below to request a time that is convenient for you.

 

We also can answer you questions by email. Please submit your question on the adjacent form

 

Patients can alternatively call our offices directly at:

 

800-515-4295

937-281-0200.

These are fill-able forms below (you can type in the information). The Firefox browser does not always work with fill-able PDF's. Please try Chrome, or Internet Explorer. If you're on a MAC, Safari should also work. 

Download Patient Form HERE

Download Uterine Fibroid Patient Form HERE

*** DO NOT EDIT THE FORM INSIDE YOUR BROWSER - DOWNLOAD TO YOUR COMPUTER AND REOPEN THE FORM - IF YOU EDIT THE FORM INSIDE YOUR BROWSER AND THEN SAVE IT, YOUR DATA MAY NOT BE SAVED (YOU'LL END UP WITH A BLANK FORM).***

Upload Completed Form Here

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).

Your Name
Your Email
Upload
Send  Reset
Full Name

Phone Number

Your Email

What condition would you like to learn more about?

How did you hear about Midwest Vein & Laser?

Your question / how we can help you?*

Get a photo consultation? (optional) Add a photo (not more than 7 Mb) of your vein or cosmetic area of concern to help us better direct your treatment:

 

Let us know if you have any questions or would like to set up a free consultation.