PHYSICIAN REFERRAL

Referring Physician

Date

Patient First Name

Patient Last Name

Date of Birth

Reason for Referral

PHYSICIAN SERVICES

VASCULAR SURGERY CONSULT (Complete – evaluation and treatment)

COMPREHENSIVE LIMB SALVAGE PROTOCOL (Testing, evaluation and treatment)

ARTERIAL EVALUATION AND PRE-OP CLEARANCE FOR PODIATRIC SURGERY

VARICOSE VEIN CONSULT

OTHER (please explain)

Please FAX referral requests to 843.573.9660. Please include demographics, insurance information, office notes, and studies pertinent to the reason for referral.

LAB TESTING FOR VASCULAR STUDY ONLY (No doctor appointment)

VENOUS

RIGHT
LEFT
BILATERAL
UPPER
LOWER
DVT (STAT)
REFLUX
VEIN MAPPING
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ARTERIAL

RIGHT
LEFT
BILATERAL
UPPER
LOWER
SINGLE LEVEL (ABI)
MULTI-LEVEL*
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HEMODIALYSIS ACCESS

RIGHT
LEFT
UPPER
LOWER
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CAROTID

RIGHT
LEFT
BILATERAL
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VISCERAL

AORTO-ILIAC
MESENTERIC *
RENAL *
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*Only available in West Ashley and Summerville

Indication/patient’s current symptoms

Physician Signature

Clear

For STAT Studies: CALL MAIN OFFICE PHONE – 843.577.4551 – before sending patient.