Physician Referral Form

At Priority Family Care, we welcome referrals from physicians and healthcare providers who trust us to deliver compassionate, comprehensive care for their patients. Our Physician Referral Form enables referring providers to share essential patient information, clinical notes, and requested services efficiently, ensuring seamless coordination of care.

Patient Name*:

Date Of Birth*:

Patient Phone*:

Insurance:

Patient Subjective Complaints / Objective Findings / Indications for Service *

Cramping while walking or at rest

Fatigue of legs when walkingt

Numbness in feet or legs

Skin discoloration in legs

Varicose veins

History/presence of legs or feet ulcers

Restless legs

History of diabetes

Varicose veins

History/presence of legs or feet ulcers

Swelling of legs/ ankles or feet

Burning or tingling feet

How far (how many minutes) can patient walk before you get cramping (claudication) or pain in your legs _____ minutes

toe or toenail changes in color and/or texture

Cold feet/toes

Legs feel heavy

Family history of circulatory/vein problem

VASCULAR SERVICES REQUESTED *

LOWER EXTREMITY ARTERIAL ULTRASOUND

UPPER EXTREMITY ARTERIA ULTRASOUND

LOWER EXTREMITY VENOUS ULTRASOUND

UPPER EXTREMITY VENOUS ULTRASOUND

CAROTID ARTERIAL ULTRASOUND

ABI

ABDOMINAL AORTA

LYMPHEDEMA CONSULT

CARDIOLOGY CONSULT

VASCULAR CONSULT

CHRONIC VENOUS INSUFFICIENCY CONSULT

DVT ultrasound with same day consult

Please note any other beneficial information about the patient or their condition:

Physician name*:

Address*:

Physician Phone*:

Email*:

Physician signature:

Date*:

REQUIRED ACTION: For expedited care, please fax this referral sheet along with any demographics, notes or studies to 877-606-7102 AND call 213-376-3762

At Priority Family Care Center, we are more than just a healthcare provider – we are your partners in achieving long-term health and well-being.

Our Locations

PFCC Site 2
Westwood
Reseda
Atlantic
Victorville

Our Services

Cardiovascular Care
Vascular Care
Podiatry Care
Primary Care

Working Hours

Monday to Saturday : 8:00 AM – 5:00 PM
Sunday : Closed

Facebook Instagram