UVWCI Requisition Order

Consult/Orders
George Wang, D.O. | Wound and Ulcer Specialist
Harout Dermendjian, M.D. | Vascular and Interventional Radiology
Kartik Kansagra, M.D. | Vascular and Interventional Radiology
Michael Lin, M.D. | Dermatology and Micrographic Dermatologic Surgery

Phone #: 661-705-9715 | FAX: 818-906-6903
Consultation Type

DERMATOLOGYVARICOSE VEINSDIABETIC NEUROPATHYPERIPHERAL ARTERY DISEASEWOUND CAREKNEE PAINBACK PAINPI (SLIP & FALL, CAR ACCIDENT)UTERINE FIBROIDS (BLEEDING)HEMORRHOIDSFISTULA/PORTSENLARGED PROSTATEOther
Patient Name*
Date of Birth*
Address
Phone #
Requested Date

MonthDayYear
Date
Requested Time

Hour Minutes

AM/PM Option
Insurance Type
Location

Nursing FacilityOfficePrivate Home
Ultrasound

Arterial US(Aortoiliac (93978), Lower Ext (93925), ABI (93922/93923/93924)) (For peripheral arterial disease, claudication, wounds.)Venous Insufficiency(93970) (For DVT, venous reflux, varicose veins, wounds.)
For Arterial US w/ ABI (L,R,B)

LRB
For Venous Insufficiency (L,R,B)

LRB
Indicate Size and Location of Wound
Anterior (Please draw here)
Posterior (Please draw here)
NOTES
Physician Name*
Physician's Signature*

Clear
Date Signed

MonthDayYear
Date
Please attach photos/images of facesheet or front and back of insurance card*

Cancelof
Should be Empty:

Consult/Orders