Consultation Referral Please complete the below form for your patient referrals. Patient DetailsPatient's Name* First Last Patient's Date of Birth Patient's Phone Number*Patient's Address Street Address Address Line 2 State / Province / Region ZIP / Postal Code Clinical DetailsImmediate(to ED or same day appointment) Acute ischaemic limb Extensive ilio-femoral DVT Axillary vein thrombosis Acute pulmonary embolism Symptomatic AAA (tenderness or rapid increase in size) Asymptomatic AAA ≥8cm Symptomatic carotid artery stenosis (Crescendo or multiple TIA or amaurosis fugax) Thrombosed or bleeding AVF Diabetic foot infection Urgent(within 1 week) Chronic limb ischaemia with rest pain, gangrene or ulceration Unprovoked DVT Recurrent DVT AAA ≥5cm Superficial thrombophlebitis Bleeding varicose veins Post-op wound breakdown False aneurysm post intervention Thoracic aortic aneurysm Asymptomatic aortic dissection Popliteal aneurysm >2cm Asymptomatic stenosis of the internal carotid artery Semi-Urgent(within 4 weeks) AAA >3cm and <5cm Claudication Asymptomatic peripheral aneurysms Malfunctioning AVF Carotid body tumour Non-healing lower limb ulcers Pelvic congestion syndrome Routine(more than 4 weeks) Varicose veins Recurrent venous ulcers Unexplained lower limb oedema Lymphoedema Arterial-venous malformation Thoracic outlet syndrome Subclavian artery stenosis Hyperhydrosis Incidental finding of mesenteric or renal artery stenosis (asymptomatic) Incidental finding of subclavian stenosis (asymptomatic) Other Add detailsLocation and ProviderLocations* Nowra Wollongong Preferred Provider* Dr Laurencia Villalba Dr Tam Nguyen ReferrerReferrer’s Name* First Last Provider Number Practice Address Street Address Address Line 2 State / Province / Region ZIP / Postal Code Referrer’s Phone Number*Referrer’s Email* MessageEmailThis field is for validation purposes and should be left unchanged. Ultrasound Referral
