Vascular Care Centrevascularcarecentre.com › ... › 10 › Vascular-Care-Centre … · Web...
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Patient Name: _________________________DOB: Phone: Reason for Referral (please tick) I mmediate (to ED or same day appointment) Urgent (within 1 week) o Acute ischaemic limb o Extensive ilio-femoral DVT o Axillary vein thrombosis o Acute pulmonary embolism o Symptomatic AAA (tenderness or rapid increase in size) o Asymptomatic AAA ≥8cm o Symptomatic carotid artery stenosis (Crescendo or multiple TIA or amaurosis fugax) o Thrombosed or bleeding AVF o Diabetic foot infection o Chronic limb ischaemia with rest pain, gangrene or ulceration o Unprovoked DVT o Recurrent DVT o AAA ≥5cm o Superficial thrombophlebitis o Bleeding varicose veins o Post-op wound breakdown o False aneurysm post intervention o Thoracic aortic aneurysm o Asymptomatic aortic dissection o Popliteal aneurysm >2cm o Asymptomatic stenosis of the internal carotid artery Semi-Urgent (within 4 weeks) Routine (more than 4 weeks) o AAA >3cm and <5cm o Claudication o Asymptomatic peripheral aneurysms o Malfunctioning AVF o Carotid body tumour o Non-healing lower limb ulcers o Pelvic congestion syndrome o Varicose veins o Recurrent venous ulcers o Unexplained lower limb oedema o Lymphedema o Arterial-venous malformation o Thoracic outlet syndrome o Subclavian artery stenosis o Hyperhidrosis o Incidental finding of mesenteric or renal artery stenosis (asymptomatic) o Incidental finding of subclavian stenosis (asymptomatic) o Other
Transcript of Vascular Care Centrevascularcarecentre.com › ... › 10 › Vascular-Care-Centre … · Web...
Patient Name: _________________________DOB: Phone:
Reason for Referral (please tick)Immediate (to ED or same day
appointment)Urgent (within 1 week)
o Acute ischaemic limbo Extensive ilio-femoral DVTo Axillary vein thrombosiso Acute pulmonary embolismo Symptomatic AAA (tenderness or
rapid increase in size)o Asymptomatic AAA ≥8cmo Symptomatic carotid artery stenosis
(Crescendo or multiple TIA or amaurosis fugax)
o Thrombosed or bleeding AVFo Diabetic foot infection
o Chronic limb ischaemia with rest pain, gangrene or ulceration
o Unprovoked DVTo Recurrent DVTo AAA ≥5cmo Superficial thrombophlebitiso Bleeding varicose veinso Post-op wound breakdowno False aneurysm post interventiono Thoracic aortic aneurysmo Asymptomatic aortic dissectiono Popliteal aneurysm >2cmo Asymptomatic stenosis of the
internal carotid arterySemi-Urgent (within 4 weeks) Routine (more than 4 weeks)
o AAA >3cm and <5cmo Claudicationo Asymptomatic peripheral aneurysmso Malfunctioning AVFo Carotid body tumouro Non-healing lower limb ulcerso Pelvic congestion syndrome
o Varicose veinso Recurrent venous ulcerso Unexplained lower limb oedemao Lymphedemao Arterial-venous malformationo Thoracic outlet syndromeo Subclavian artery stenosiso Hyperhidrosiso Incidental finding of mesenteric or
renal artery stenosis (asymptomatic)o Incidental finding of subclavian
stenosis (asymptomatic)o Other
Clinical Comments
Imaging tests performed :
Referred by:__________________________________________ Phone:
Provider No: ___________________________________________Fax:
