Harbour Vascular - Aesthetic

Full Name *

DOB *

Street Address *

Suburb & Postcode *

Email Address *

Phone *

What are your main concerns? *

What treatments have you had before? *If none, please write NONE

Have you had a recent venous insufficiency ultrasound? *

YesNo

Please attach a copy of the results

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If you don't have an electronic copy of your results, please arrange to bring a copy of your results / imaging to your appointment.

For some cases, we may recommend an ultrasound through our advanced vascular laboratory to ensure optimal results. If this is necessary, a referral from your GP will be required. They may use the Harbour Vascular Ultrasound form here.

If you choose not to pursue the ultrasound, we can still provide high-quality care without a referral. Your comfort and satisfaction are our top priorities, and we tailor our services to meet your needs.

Referral Date