Refer a Patient

veinoux

healthy flow, Optimized

Address: 1328 Southern Avenue #217, SE. Washington DC 20032
Website: www.veinoux.com
Email: info@veinoux.com
7801 Old Branch Ave. #202, Clinton MD 20735
Contact: 1-202 221 8442
FAX: 1-202 221 8443

REFERRAL FORM

PATIENT INFORMATION

PATIENTS NAME


PATIENTS PHONE #


REFERRING PHYSICIAN


OFFICE ADDRESS


OFFICE NUMBER


OFFICE FAX


EVALUATE/TREATMENT ROUTINE/ 72HRS/ 48HRS/ 24HRS.

Cerebrovascular Ultrasound (Carotid/Vertebral Doppler)

Peripheral Arterial (Segmental Pressures/ Doppler)

Bypass Graft Duplex Ultrasound

Asymptomatic Carotid Bruit

Claudication

Surveillance

Transient Ischemic Attacks (TIA)

Rest Pain

Clinical Changes

Stroke

Gangrene

Cold Foot

Amaurosis Fugax

Non-healing Ulcers

Trauma

Known Carotid Stenosis

Absent Pulses

Other (ICD-10 code)

Post-Op Assessment

Post-op BPG

Percutaneous Tenotomy/Fasciotomy

CONDITIONS

Acute Venous Ultrasound (Lower/Upper)

(Bilateral/Unilateral, Right/Left

Abdominal Arterial Ultrasound

(SMA, Celiac, Aorta, Iliac)

OTHER STUDIES

Pain < 72hrs

Suspected/Known AAA

Renal Duplex ultrasound

Swelling < 72hrs

Back Pain

Peripheral Artery USG

Vein Mapping for Bypass

Post Prandial Pain

Dialysis Graft USG

Varicose Veins/Reflux

Hip Claudication

AV fistula USG

Pulmonary Embolism

Post-Surgical Pain

OTHER ICD-10

High Risk (Carcinoma, Anti-coagulation, trauma)

Carpel Tunnel Syndrome

OTHER ICD-10

As Always, we thank you for your referral. We will send appropriate progress notes.




VEINOUX HEALTHY FLOW, OPTIMIZED





Veinoux Healthy Flow, Optimized




About Veinoux



We assist healthcare facilities and institutions to develop and operate quality vascular access program to improve patient satisfaction.

Locations



❖ 7801 Old Branch Ave. #202, Clinton MD 20735
❖ 1328 Southern Avenue #217, SE. Washington DC 20032

800 676-8979



Call 911 for all medical emergencies.




Copyright  Veinoux 2019. All rights reserved.



Copyright Veinoux 2019. All rights reserved.