Patient's First Name *

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Referring MD *

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Insurance *

Vein Evaluation

Vein Evaluation

Varicose Veins
Spider Veins
Edema
Restless Leg Syndrome
Venous Stasis
Leg Pain
Claudication
Lower Extremity Ulcer
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Ultrasound

Ultrasound

DVT
Venous
Arterial
ABI
Carotid
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Hemorrhoid Consult

Hemorrhoid Consult

Yes
No
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Additional Notes

Diagnosis Code *

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