Harbour Vascular Referral

Vascular / Endovascular Surgeon ReviewAesthetic Dermal Laser TherapyUltrasound Duplex AssessmentComplex Wound Review

Full Patient Name *

DOB *

Patient Street Address *

Patient Suburb & Postcode *

Patient Phone *

ULTRASOUND DUPLEX ASSESSMENT

ARTERIAL

Carotid & Vertebral UltrasoundAnkle-Brachial Index (ABI)Lower Limb - LEFTLower Limb - RIGHTLower Limb - BILATERALAorto-iliac/ AAA UltrasoundRenal Artery UltrasoundMesenteric Artery UltrasoundUpper Limb - LEFTUpper Limb - RIGHTUpper Limb - BILATERAL

VENOUS - RIGHT

DVT LowerDVT UpperVaricose Veins Ultrasound (Venous Insufficiency)IVC / Iliac veinsOvarian / Pelvic VeinsPerforator MarkingConduit Marking

VENOUS - LEFT

DVT LowerDVT UpperVaricose Veins Ultrasound (Venous Insufficiency)IVC / Iliac veinsOvarian / Pelvic VeinsPerforator MarkingConduit Marking

ARTERIOVENOUS FISTULA

MappingSurveillanceLowerUpperRightLeft

VASCULAR DISEASE SCREENING

Consists of Carotid Ultrasound - cerebrovascular screenABl’s - screen for peripheral arterial diseaseAorta Ultrasound - screen for AAA

THORACIC OUTLET SYNDROME

RightLeft

Other

COMPLEX WOUND REVIEW

Medical History *

Medications *

Reason for Wound Referral *

Wound Care Regime - Previous or Current *

Nutritional Supplements Being Used

For Pressure Injuries, Equipment Currently in Place

Pressure Injury Prevention & Continence Management Strategies in Place

For Lower Limb Vascularisation, is a Vascular Specialist involved? *

YesNo

Name and Contact Details *

Has the Patient Been Reviewed by a Vascular Specialist in the Last 6 Months? *

YesNo

Please Provide Report / Outcome *

Please provide the following

Wound PhotographyRecent Wound SwabRecent Pathology ResultsRecent Antibiotic Treatment

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Is GP involved with wound management? *

YesNo

Does GP want to be involved in case conferencing? *

YesNo

Are telehealth facilities available? *

YesNo

VASCULAR / ENDOVASCULAR SURGEON REVIEW

AESTHETIC DERMAL LASER THERAPY

Clinical Details *

Referring Doctor *

Practice Address *

Email Address *Will receive a copy of this referral along with future correspondence

Provider Number *

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Referral Date

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