POLAR™ Healthcare | Vascular Access Referral Form
FAX SECURE: (281)-606-0455
Please FAX Patient's History & Physical with Recent Labs (CBC / PTT / INR) and Provider's Order for Vascular Access
Patient Full Name
Indicate patient's full name
Date of Birth
Indicate patient's date of birth
Gender
Male
Female
Other
Patient Phone Number
Indicate patient's phone number
Patient Email Address
example@example.com
Patient Home Address
Please indicate patient's Home Address
MRN If Applicable
Referring Provider
*
Please Indicate Provider (MD, PA, NP)
Signature
Provider NPI:
Please Indicate Provider NPI Number
Today's Date
-
Month
-
Day
Year
Indicate Date of Provider Signature
Clinic / Facility
Indicate name of clinic or facility initiating referral
Facility Phone
Indicate reliable call back number of clinic or facility initiating referral
Facility FAX
Indicate clinic or facility FAX number
Vascular Access Services Order
PICC Line (PowerPICC+ 3CG Confirmation)
MIDLINE Catheter(PowerGlide / Extended Dwell)
Ultrasound Guided Placement
Single Lumen - PICC
Double Lumen - PICC
Triple Lumen - PICC
Secure with Sutures
Type in other orders not listed above
Please indicate any additional orders
Urgency of Order
Activate POLAR™ STAT (<4 Hours Placement)
Routine Placement (Non-emergent)
Clinical Indications
IV Antibiotics
TPN / Nutrition Support
Chemotherapy / Infusion
Other
If 'Other' for Clinical Indication
Please indicate purpose for Vascular Access Service
Insurance Provider
Please indicate patient insurance provider
Policy Number
Please indicate policy number
Group Number
Please indicate policy number
POLAR™ Healthcare |
Vascular Access Referral
Form
info@polarhealthcare.net www.polarhealthcare.net
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