Vascular Health Group | Patient Referral

Referring doctors should be aware that Deep Vein Thrombosis (DVT) scans are Bulk Billed by our practice.

Please note: items marked * indicate mandatory fields.

Referring Doctor Name *

Referring Doctor Practice Name

Referring Doctor Provider # *

Referring Doctor Address

Referring Doctor Suburb

Referring Doctor State

Referring Doctor Postcode

Referring Doctor Phone *

Please enter phone number with area code included. No spaces please. eg. 0298765432

Referring Doctor Email

Patient First Name *

Patient Last Name *

Patient Date of Birth *

Day

Month

Year

Patient phone *

Please enter phone number with area code included. No spaces please. eg. 0298765432

Investigation request *

Other *

Patient clinical condition / details *

Body Position *

Report *

Routine

Urgent

File Attachment

Add a new file *

Files must be less than 2 MB.
Allowed file types: gif jpg jpeg png txt rtf odf pdf doc docx.

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