Date MM slash DD slash YYYY Name of Referring Dr.* First Last Referring Dr. location:* AbingdonBelvedereColumbiaEssexGlen BurnieLuthervilleHagerstownHanoverHavre de GraceLaurelPikesvilleRosedaleWestminsterYork Referring Dr. Phone #* Email Referring Dr. Fax # Name of patient you are referring* First Last Type of visit being requested Vascular / Wound Consultation Testing Patient's DOB* MM slash DD slash YYYY Patient's Phone #* Type of insurance What location are you referring patient to:* AbingdonBelvedereColumbiaEssexGlen BurnieLuthervilleHagerstownHanoverHavre de GraceLaurelPikesvilleRosedaleWestminsterYork Patient Documents* Drop files here or Select files Max. file size: 100 MB. Please attach patient's demographics, insurance information and most recent office note. Please select each test request below and all the reasons that apply for each test. ARTERIAL: Lower Arterial Evaluation Claudication Decreased Pulses Leg Ulcer Rest Pain Gangrene Digital Cyanosis (Raynaud or Buerger) Bypass Graft (if applicable) Stent (if applicable) Physiologic Testing (ABI's and/or TBI's, treadmill Duplex: Aortoilliac & femoropopliteal prn Specify location: Carotid Duplex Ultrasound Bruit Amaurosis Fugax TIA CVA Upper Arterial Evaluation Subclavian Steal Syndrome Thoracic Outlet Syndrome Digital Cyanosis (Raynaud or Buerger) Claudication Abdominal Aortic Duplex R/O AAA Mesenteric Artery Duplex R/O Mesenteric Ischemia Renal Artery Duplex Uncontrolled HTN / R/O Renal Artery Stenosis VENOUS: Venous Duplex (Upper or Lower Extremity) Acute Edema - R/O DVT (STAT) Chronic Edema - Venous Insufficiency, Reflux / Varicose Veins R, L, Bilateral DIALYSIS VASCULAR ACCESS SITE: Dialysis Access Site Evaluation Pre-op Access Site - Right Pre-op Access Site - Left SPECIALIZED VENOUS: Pelvic Congestion Syndrome (New Exam) Yes Duplex of the Iliocaval, Ovarian veins and Left Renal Vein 8 hrs fasting; OTC anti-gas medication recommended Iliocaval Duplex (May-Thurner Syndrome) Right Left Upper Lower Vein Mapping Duplex Yes OTHER Diagnosis/Reason* Comments Attach Demo Sheet Drop files here or Select files Max. file size: 100 MB. Signature* Email This field is for validation purposes and should be left unchanged. Δ By submitting this form, you agree to our Terms of Use.