Peripheral Vascular Evaluation
TEL:  (832) 781 - 0000
FAX:  (832) 781 - 1000
www.flowvascular.com
Today's Date: Requested Procedure Date: Date of Last HD (if applicable):
 
 
 
 
 
 
 Patient Information
First Name: Last Name:
Patient Phone:  Date of Birth:
 
 
Referring Physician / Practice
Referring Physician: Phone #:
Referred by:




Preferred Flow Vascular
Location:


 
Location


 
Indication
 Swollen / Painful Extremity  Non-Healing Wound  History of PVD  Gangrene
 Low / No Circulation  Foot Wound  Vein Disease  
 
Other
Clinical Information
X-Ray Contrast Allergy?  Yes  No
Other Medication Allergy?  Yes  No
Blood Thinner or Bleeding Disorders?  Yes  No
Contagious Diseases ? 
Known problem with anesthesia?  Yes  No
Competent to sign consent form?  Yes  No
Transportation Needs
Does the patient have their own transportation?     Yes      No
Does the patient need transportation arranged?     Yes      No