Access Vascular Referral – Access Vascular

Patient Details

Patient Name *

First

Last

Address

Address Line 1

City

State / Province / Region

Postal Code

Country

Date of Birth

Phone

Medicare Number

Clinical Details

Medical History / Medications:

Specific Clinical Query?

Urgent

Please Indicate if this appointment is urgent

Ultrasound Tests Required

(All testing is bulk billed)

CAROTID-VERTEBRAL ARTERIAL DUPLEX

Yes

PERIPHERAL ARTERIAL DISEASE – lower limb (Claudication, Ulcer, Rest Pain)

Right
Left

Leg Arteries

Right
Left

AORTA AND ILLIAC arteries

Yes

Arm Arteries

Right
Left

Ankle‐Branchial Index (ABI)

Resting
Exercise

DVT STUDY – lower limb

Femoro-tibial and Superficial veins

Right
Left

IVC and iliac veins

Right
Left

DVT STUDY – upper limb (brachial, subclavian, innominate)

Right
Left

VENOUS INSUFFICIENCY STUDY

Femoral, Popliteal, tibial and Superficial veins

Right
Left

IVC and Iliac veins

Right
Left

ABDOMINAL VENOUS (for venous diseases including DVT)

IVC and iliac veins

Right
Left

Ovarian, renal, iliac veins

Right
Left

COMMON FEMORAL VEIN ONLY

Resting
Exercise

RENAL ARTERIAL DUPLEX (Hypertension, arteritis)

Yes

VISCERAL ARTERIAL DUPLEX (Abdominal Angina, aneurysm)

Yes

OTHER (Please specify)

Consultation

Referring Doctor

Name

Provider

Signature

Date / Time

Practice Name

Contact Number

Location

Send a copy to *

a copy of the referral will be sent to email provided