Online Referral

(08) 9389 8658

Download Referral Form

Patient Name *

First

Last

Patient Contact Number *

Patient Date of Birth *

Postal Address *

State *

Postcode *

Date of Birth *

Contact Number

Examination Required

(ALL TESTING IS BULK BILLED)

VENOUS INSUFFICIENCY STUDY:

Layout

Femoral, Popliteal, tibial and Superficial veins

Right
Left

IVC and Iliac veins

Right
Left

ABDOMINAL VENOUS (for venous diseases including DVT)

Layout

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)

Telehealth Appointment

Yes

Cardiologist

Dr Robert Tewksbury Vascular & Endovascualr Surgeon

Clinical Details

Medical History / Medications

Specific Clinical Query

Who is Your Referring Doctor?

Name *

Signature *

Practice Name *

Practice EDI (Health Link)

Provider No. *

Date

Copy of report to:

Locations

Preferred Locations

Nedlands
Joondalup

Website