ADVANCED VASCULAR ONLINE REFERRAL

Patient Referral Form
Preferred Location*

Portland LocationEugene Location
Stat*

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DATE*

MonthDayYear
Date
Patient's Full Name*

First NameLast Name
Phone*
Email*
example@example.com
DOB*

MonthDayYear
Date of Birth
ICD10
Reason for Referral*
Provider's Name*

First NameLast Name
Provider's Phone*
Fax
REASON FOR REFERRAL
VEIN PROCEDURES

Acute DVTVenous DiseaseVenous Statsis WoundsSpider Vein EvaluationTreatment of May-Thurner Syndrome
ANGIOGRAPHY & INTERVENTIONS

Peripheral Arterial Disease (PAD)ClaudicationCritical Limb Ischemia (Non-healing wounds, rest pain, limb salvage)Arterial WoundsDiabetic Foot UlcerDialysis Access Maintenance: Catheters, Fistulas, Grafts
ONCOLOGY

Vertebral Ablation (RFA)Regional Liver Therapy for Cancer (Chemo Embolization, Thermal Ablation)Pre-Op Embolization (Renal, Bone, Glomus, Soft Tissue Mass)Cryoblation of Liver, Lung, Soft Tissue, Bone and Kidney MassesPleurx Catheter for Chest or AbdomenBiliary Tube Placement/ Exchange/EvaluationVenous Access (Port, PICC, Permcath) Placement, Exchange, Removal
EMBOLIZATION PROCEDURES

Uterine Fibroid EmbolizationPelvic Venous DisordersMale VaricoceleProstate Artery Embolization
MINOR PROCEDURES

Liver BiopsyThoracentesisParacentesisThyroid Biopsy/ Fine Needle AspirationNodal Biopsy
OTHER PROCEDURES

Vertebroplasty/KyphoplastyIVC Filter Placement/Removal/Reposition
SPECIALIZED DIAGNOSTIC ULTRASOUND EXAMINATION REQUEST
UPPER/LOWER EXTREMITY

Arterial/Doppler/Duplex (ABI, PPG, and/ or segmental pressures,imaging) Lower or Upper extremityPlanter Acceleration Time (Foot Profusion)Venous Doppler Duplex (Bilateral/Unilateral arm or leg to rule out DVT, pelvic venous outflow; unilateral study inclusive of contralateral comparison)Venous Doppler Reflux (study to determine the presence of lower extremity venous valvular reflux; includes venous protocol listed above)Abdominal Duplex (complete study; arterial inflow and venus outflow of abdominal, pelvic, scrotal contents or retroperitoneal organs)Aorta with Doppler complete study; retroperitoneal - renal, aorta, nodesCarotid and Vertebral Artery Duplex (extra cranial evaluation)Dialysis Graft Duplex (hemodialysis access evaluation - arterial & venous inflow & outflow)Renal Duplex (limited study; retroperitoneal)
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Improving Outcomes with Advanced Options

PORTLAND

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Portland, OR 97223
Phone: (503) 683-7730
Fax: (503) 914-0927
info@advasc.com

EUGENE

1200 Gateway Loop
Springfield, OR 97477
Phone: (541) 933-0800
Fax: (541) 204-1997
eugene@advasc.com

WE HAVE A SPECIALIZED ULTRASOUND TEAM ON STAFF
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Patient Referral Form

REASON FOR REFERRAL

SPECIALIZED DIAGNOSTIC ULTRASOUND EXAMINATION REQUEST

WE HAVE A SPECIALIZED ULTRASOUND TEAM ON STAFF