Patient Referral and Information Sheet

* Patient Name:
* Referring Physician:
* Date: / /
* Time: :
* 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