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VASCULAR ULTRASOUND REFERRAL FORM Appointment Scheduling: 310-423-8000 and press 1 Fax all orders to: 310-423-0137 Patient Name: Date of Exam: Date of Birth: Arrival Time: MM/DD/YYY Aneurysm ??? Aorta

How to fill out vascular ultrasound referral form

How to fill out a vascular ultrasound referral form:

1. Start by providing your personal information, such as your full name, address, date of birth, and contact number. This information is essential for identification purposes and for the ultrasound facility to reach out to you if needed.
2. Next, indicate the reason for the referral. Specify the symptoms or medical conditions that led your healthcare provider to recommend a vascular ultrasound. This information helps the ultrasound technician understand what needs to be evaluated during the procedure.
3. Specify any relevant medical history or pre-existing conditions that may impact the vascular ultrasound. For example, if you have a history of blood clots or have undergone any previous vascular surgeries, it's important to mention them on the referral form. This enables the ultrasound technician to tailor the procedure to your specific needs.
4. If you have any allergies, make sure to include them on the form. Certain ultrasound contrast agents or medications used during the procedure may contain substances that could cause an allergic reaction. By providing this information, the ultrasound facility can take appropriate measures to ensure your safety.
5. Indicate any medications you are currently taking, including prescription drugs, over-the-counter medications, and dietary supplements. Some medications may interfere with the vascular ultrasound or require special consideration during the procedure. By listing all the medications you are taking, you help the ultrasound technician and interpreting physician get a comprehensive view of your health.

Who needs a vascular ultrasound referral form?

A vascular ultrasound referral form is typically required for individuals who have been clinically evaluated and require further diagnostic assessment of their blood vessels. This includes patients with symptoms or risk factors for vascular diseases, such as peripheral artery disease (PAD), deep vein thrombosis (DVT), carotid artery stenosis, varicose veins, or aneurysms. Additionally, individuals who have undergone specific surgeries or treatments, such as coronary artery bypass or dialysis, may also need a vascular ultrasound referral form to monitor the health and functionality of their blood vessels. Ultimately, it is the healthcare provider who determines the need for a vascular ultrasound referral form based on the individual's medical history, symptoms, and overall clinical assessment.

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What is vascular ultrasound referral form?

A vascular ultrasound referral form is a document used to request a vascular ultrasound examination for a patient.

Who is required to file vascular ultrasound referral form?

Medical professionals such as doctors, physician assistants, or nurse practitioners are required to file the vascular ultrasound referral form.

How to fill out vascular ultrasound referral form?

The form typically requires the patient's personal information, medical history, reason for the ultrasound request, and any relevant clinical notes or test results.

What is the purpose of vascular ultrasound referral form?

The purpose of the form is to facilitate the scheduling and performance of a vascular ultrasound examination to evaluate blood flow in the arteries and veins.

What information must be reported on vascular ultrasound referral form?

The form may require information regarding the patient's symptoms, medical history, current medications, and any relevant diagnostic tests.

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