GP Referral
Surname
UR
Given Name
DOB
Address
Phone
Ref Dr
Ph
Address
Provider Number
Clinical Details

Colour Duplex Scans (Please Tick)

 Cerebrovascular (Carotids) Graft Surveillance Lower Limb Arterial Lower Limb DVT Venous Insufficiency (Varicose Veins) Upper Limb Arterial Upper Limb DVT Thoracic Outlet Syndrome Fistula Scan/Mapping Other (Specify)

The following Scans require a 4 hour fast

 Abdominal/Aortoiliac Renal Vessels Visceral Vessels

Test Required (Please Tick)

 Resting Ankle Pressure Exercise Ankle Pressure Toe/Finger Pressures

Results

 Tel Report to

 Images and report returned with patient

 Fax Report to

Copies to

 Argus Link

Appointment is booked on at

WE BULK BILL - This referral can be used at any Diagnostic Imaging Centre