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Access Vascular
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Access Cardiology
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Refer Now
About Us
Services
Treatment / Focus
Telehealth
Education & Information
For Medical Professionals
Online Referral
Referral Templates
Request Referral Pads
Contact Us
Online Referral
(08) 9389 8658
Download Referral Form
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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)
Layout
Examination Required
CAROTID-VERTEBRAL ARTERIAL DUPLEX
Leg Arteries
Right
Left
Arm Arteries
Right
Left
DVT STUDY – lower limb
Femoro-tibial and Superficial veins
IVC and iliac veins
PERIPHERAL ARTERIAL DISEASE – lower limb (Claudication, Ulcer, Rest Pain)
Right
Left
AORTA AND ILLIAC arteries
Right
Left
ANKLE-BRANCHIAL INDEX (ABI)
Resting
Exercise
DVT STUDY – upper limb (brachial, subclavian, innominate)
Right
Left
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
*
Clear Signature
Practice Name
*
Practice EDI (Health Link)
Provider No.
*
Date
Copy of report to:
Locations
Preferred Locations
Nedlands
Joondalup
Website
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