Patient Referral and Information Sheet

* Patient Name:
* Referring Physician:
* Date:	/ MM / DD YYYY
* Time:	: HH MM AM PM AM/PM
* Indication / Symptoms:
* Primary Insurance:

• Echocardiography
  • 2-Dimensional [93307]
  • Color [93320]
  • Doppler [93325]
• Carotid Doppler Exam [93880]
• Extremity Arterial Exam
  • Upper Extremity Duplex [93930]
  • Lower Extremity Duplex [93925]
  • Segmental Pressures Limited [93922]
  • Segmental Pressures Complete [93923]
• Venous Duplex/Color [xxxx]
  • Upper Extremity [93970]
  • Upper Extremity Limited [93971]
  • Lower Extremity [93970]
  • Lower Extremity Limited [93971]
• Abdominal Exams
  • AAA [93978]
  • Renal Vascular [93975]
  • Mesenteric Vascular [93976]
• Other

• Cardiovascular Ultrasound Services, Inc.
• Phone:(614) 870-3301
• Fax:(614) 870-1121

• Physicians:
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  Patients:
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