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PHYSICIAN REFERRAL FORM
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Cardiovascular Care
Podiatry
Primary Care
Vascular Care
Submit Event
User Profile
Venue
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 walking
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:
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
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