REFERRAL FORM

Use this form to send referrals directly to our team.

Patient's Name

Date of Birth

Patient Phone

Address

Room #

Primary Insurance

Secondary Insurance

Referring Physician

NPI #

Provider email

Name of Individual Completing Form

Provider Office Phone

Physician Signature

Instructions/Clinical History

You must select at least one exam from the list below.

Arterial Doppler

Arterial Doppler Lower Extremity R

Arterial Doppler Lower Extremity L

Arterial Doppler Lower Extremity BIL

Arterial Doppler Upper Extremity R

Arterial Doppler Upper Extremity L

Arterial Doppler Upper Extremity BIL

Venous Doppler (DVT)

Venous Doppler Lower Extremity R

Venous Doppler Lower Extremity L

Venous Doppler Lower Extremity BIL

Venous Doppler Upper Extremity R

Venous Doppler Upper Extremity L

Venous Doppler Upper Extremity BIL

Other Study

DIAGNOSTIC CODES

R21.3 Acute Myocardial Infarction unspecified site

I77.9 Unspecified of arteries and arterioles

I73.9 Peripheral vascular disease, unspecified

R60.9 Edema

Other DX code:

Thanks for your referral!