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GP Referrals
GPs can fill in the form below to submit a referral.
Patient Information
First Name
*
Last Name
*
D.O.B
*
Date Format: MM slash DD slash YYYY
Telephone
*
Address
Medicare/ DVA
Scanning
Please tick the boxes below to request the Scan you require
ARTERIAL SCANNING
*
AAA / EVAR follow-up
Ankle Brachial Index
Aorto Iliac Arteries
AV Fistula SITE _________________
Carotid and Vertebral Arteries
Graft Surveillance SITE ____________
Lower Limb Arteries - LEFT
Lower Limb Arteries - RIGHT
Mesenteric Arteries
Popliteal Entrapment
Renal Arteries
Upper Limb Arteries - LEFT
Upper Limb Arteries - RIGHT
VENOUS SCANNING
*
Ovarian and Pelvic Vein
Thoracic Outlet Assessment
Upper Limb Veins
Varicose Veins - LEFT
Varicose Veins - RIGHT
Vein Mapping - Upper Limb
Vein Mapping - Lower Limb
Venous Thrombosis (DVT) - LEFT
Venous Thrombosis (DVT) - RIGHT
OTHER
CLINICAL DETAILS
Referring Doctor
DOCTOR’S NAME
PROVIDER NUMBER
ADDRESS
CLINIC
Date
*
Date Format: DD dash MM dash YYYY
COPIES TO
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