DOPPLER/ULTRASOUND REQUEST
Date
/
Month
/
Day
Year
Date
Patient Name
DOB
Patient Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Ins
Secondary Ins
Reason for Referral/Diagnosis
Referring Provider
Referring Facility
Provider Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Provider Fax
Please enter a valid phone number.
Format: (000) 000-0000.
Provider Signature
Routine or STAT?
STAT
ROUTINE
DOPPLER EXAMS
Please check the box indicating the requested exams:
ARTERIAL WITH ABI
Bilateral
Upper Extremity
Lower Extremity
VENOUS
Bilateral
Upper Extremity
Lower Extremity
CAROTID
HEPATIC
AORTILIACS
RENAL
MESENTERIC
ULTRASOUND
ABDOMINAL
COMPLETE
LIMITED
THYROID
SCROTUM
KIDNEY/BLADDER
SOFT TISSUE/HERNIA
AAA SCREENING
BLADDER PVR
KIDNEY
CARDIAC
ECHOCARDIOGRAM
OB/GYN
1ST TRIMESTER
PELVIC
ENDOVAGINAL
Other
MUSCULOSKELETAL/SOFT TISSUE
SHOULDER
LEFT
RIGHT
HIP
LEFT
RIGHT
ELBOW
LEFT
RIGHT
WRIST
LEFT
RIGHT
KNEE
LEFT
RIGHT
ANKLE
LEFT
RIGHT
INGUINAL
LEFT
RIGHT
COMPRESSION STOCKINGS
Evaluate and fit for appropriate stockings
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