Vascular/Endovascular Surgeons
Dr Steve Baker
Dr Rick Bond
Prof Patrice Mwipatayi
Dr Gregory (Chui) Then
Dr Patrik Tosenovsky
ACN 089 068 897 and ABN 43 089 068 897
www.cvs.net.au
For All Appointments and Reports Tel: 1300 887 997 or Fax: (08) 9389 5322
PLEASE BRING THIS REFERRAL TO YOUR APPOINTMENT
Patient Name: [PAT_FIRSTNAME] [PAT_SURNAME]
Address: [PAT_HOME_STREET]
[PAT_HOME_SUBURB] [PAT_HOME_POSTCODE]
Phone: Home [PAT_HOME_PHONE] Mob: [PAT_CELL_PHONE]
Date of Birth: [PAT_DOBL]
Arterial Examination Requested:
Venous Examination Requested:
Carotid Doppler
AAA Study
*Peripheral Arterial Study
Aorto-Iliac Artery Duplex
Arterial Lower Limb
L
R
Arterial Upper Limb
L
R
ABI: Ankle Brachial Index
Specify:
Renal Artery Duplex
Mesenteric Artery Duplex
DVT: Deep Vein Thrombosis
L
R
URGENT
Venous Lower Limb
L
R
Venous Upper Limb
L
R
Ovarian and Pelvic Veins
Vein Mapping
Specify:
Arteriovenous Fistula
Other
*A Peripheral Arterial Study includes duplex scans to the abdominal, femoral, popliteal and tibial arteries.
Depending on a patient's condition and geographical location this will in most instances require more than one attendance.
Vascular Consultation Required
Dr Steve Baker
Dr Rick Bond
Tel: 9310 1022
Tel: 6397 5120
Prof Patrice Mwipatayi
Dr Gregory (Chui) Then
Dr Patrik Tosenovsky
Tel: 9386 9588
Tel: 9310 2377
Tel: 9389 1533
Clinical Query?
Clinical History
[FRN_CURRENT_DX]
Medications
[FRN_LONGTERM_RXL]
________________________________________________________________________________________________
Referring Doctor: [PROV_NAME]
Provider Number: [PROV_PROVIDER_NO]
Referring Doctor's Signature:
Surgery: [LOC_NAME]
Phone: [LOC_DAY_PHONE]
Date: [MIS_DATE]
Fax: [LOC_FAX_PHONE]
Copy of Report To Doctor:
Locations
Nedlands - Consult
Nedlands - Testing
Kalamunda
Leeming
Midland
Rockingham
Suite 8, 95 Monash Ave
Suite 13, 95 Monash Ave
Unit 3, 37 Elizabeth St
Suite 3, 73 Calley Dr
Suite 2, 9 The Avenue
Suite 1, 221 Willmott Dr
Joondalup
East Fremantle
Karrinyup
Mandurah
Inglewood
Suite 205, Lvl 2, Joondalup Health Campus,65 Shenton Ave
Suite 5, 163 Canning Hwy
40 Davenport Street
Suite3, South Consult Suite, Peel Health Campus
UnitA, 826 Beaufort St
Your doctor has recommended that you use CVS. You may use another provider but please discuss this with your doctor first