Vascular Referral Form by Physician

REFER A PATIENT

Vascular Referral by Physician to:
DON W. BROWN, D.O., FACS, FACOS
Vascular Surgeon

50 MedPark Square Drive Suite 3 Somerset, Kentucky 42503 | Phone: 606-531-4100 | Fax: 606-220-2116

www.southernkentuckyvascular.com
When does the Patient need to be seen? (Choose one)

ASAPFirst Available
Preferred Location

Somerset, KYDanville, KYLondon, KYRussell Springs, KYGlasgow, KYCampbellsville, KYStearns, KYManchester, KY
Patient Details
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Patient Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Home Phone Number
Patient Work Phone Number
Patient Mobile Phone Number*
Email
example@example.com
Patient Insurance*
Send or Upload a copy of Pt. Insurance Card
Upload a scanned copy of Pt. Insurance Card - Front
Upload a scanned copy of Pt. Insurance Card - Back
Referring Physician Details
Referring Physician Name*

First NameLast NameSuffix
Practice Name
Practice
Practice Phone Number*
Main Phone Number
Primary Contact Person Name*

First NameLast Name
Primary Contact Phone Number*
Contact Person Phone Number
Contact Person Email*
example@example.com
Reason for Visit

Indicate the Reason for the Referral

	Select Reason for Visit Below
Peripheral Arterial Disease
Peripheral Vascular Disease
AAA
Carotid Artery Stenosis
Venous Insufficiency
DVT/PE
Mesenteric Stenosis
Swelling, Upper Extremity
Swelling, Lower Extremity
Fistula Creation
Hyperhidrosis
Varicose Veins
Non-Healing Wounds
Renal Stenosis
Other

Supplemental Notes about the patient's condition:
Notes & Studies to send with Vascular Referral
Please check the items accompanying this referral:

Referring NoteUpdated Medication ListCopy of insurance cardsCT or MRIs related to the appointment (abdomen, pelvis, with or without runoff) within the last yearCTA or MRA of neck – within the last yearABI (Ankle Brachial Index) - within the last 6 monthsAngiogram (post-op reports- renal, peripheral, carotid) – within the last yearUltrasounds or Doppler Studies - carotid artery, arterial duplex of any extremities, abdominal, venous (for DVT or insufficiency studies) - within the last 6 months
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REFER A PATIENT