Vascular Referral Home Vascular Referral VASCULAR REFERRAL FORM Complete this form to refer your patient for vascular tests. Required Test(s) Abdominal Aortic Aneurysm Ultrasound (AAA) Ankle-Brachial Index, Toe-Brachial Index (ABI+TBI) Arteriovenous Fistula Ultrasound Carotid Duplex Ultrasound Diabetic Foot Screen DVT Study of Bilateral Lower Limbs DVT Study of Bilateral Upper Limbs DVT Study of Lower 1 limb DVT Study of Upper 1 limb Erectile dysfunction Hemodynamic Study (EDHS) Light Reflex Rheography (LRR) Pelvic Duplex Ultrasound (TA/TV) Peripheral Arterial Hemodynamic Study (PAHS) Renal Vascular Duplex Ultrasound US Duplex Arterial of Bilateral Lower Limbs US Duplex Arterial of Bilateral Upper Limbs US Duplex Arterial of Lower 1 limb US Duplex Arterial of Upper 1 limb US Vein Map for AV Fistula - Bilateral US Vein Map for AV Fistula - Unilateral Venous Hemodynamic Study (VHS) Venous Incompetency Scan (Varicose Veins) - Bilateral lower limbs Venous Incompetency Scan (Varicose Veins) - Lower 1 limb Others Other Test Required Clinical Notes (Optional) Preferred Test Date / Time Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December Year 20262027202820292030 Bill To Select Billing Option Bill Clinic Bill Patient Patient Details Patient Date of Birth Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December Year 20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Gender: Male Female Clinic Details Patient's next appointment with referring doctor Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December Year 20262027202820292030 I understand and agree to the privacy policy. Submit Book a visit Take the first step toward better health today Book Appointment Book Teleconsult
