VASCULAR DIAGNOSTICS ULTRASOUND REFERRAL
PATIENT DETAILS
Name
DOB (dd/mm/yyyy):
Phone no:
Clinical indication:
TEST(S) REQUIRED – PLEASE TICK
LOWER LIMB ARTERIAL
Bilateral ABI & toe pressures at rest
Bilateral exercise ABI
Right leg
Left leg
UPPER LIMB ARTERIAL
Right arm
Left arm
Bilateral brachial pressures
Right finger pressures
Left finger pressures
CEREBROVASCULAR
Carotid & vertebral arteries
Temporal arteritis (incl. SCA & Ax A)
ABDOMINAL – Please follow fasting instructions
Abdominal aorta & iliac arteries
Mesenteric arteries
Renal arteries
Preoperative renal transplant assessment
Renal allograft (post transplant)
IVC & iliac veins
Ovarian / gonadal veins
LOWER LIMB VENOUS
Right leg DVT
Left leg DVT
Right leg venous insufficiency
Left leg venous insufficiency
UPPER LIMB VENOUS
Right arm
Left arm
ARTERIOVENOUS FISTULA
Right arm mapping
Left arm mapping
Progress / surveillance
ARTERIAL / VENOUS MAPPING (please specify right or left in comments)
Right / left leg perforators pre op
Right / left leg GSV for bypass
Right / left arm radial arteries for bypass
Right / left arm cephalic and basilic veins for bypass
Central venous access
Miscellaneous assessment/comments
Please specify:
REFERRING DOCTOR DETAILS
Name
Provider no:
Routine
Urgent
Other
Comments:
0
/500
Date (dd/mm/yyyy):
LOCATION AND CONTACT DETAILS
2 – 4 Speed Street Liverpool 2170, ground floor
Fax: (02) 8711 8819
Phone: (02) 8734 3156
Email: info@liverpoolclinic.com.au
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