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
*Bowling Green Phone: 270-260-1006 | 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, KYBowling Green, 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