Referral for Evaluation and Treatment
Michael Lalezarian, MD, Medical Director
Send By Fax
310.861.8824
or Email:
info@provascularmd.com
Please provide: face sheet, insurance cards, H&P, meds list, and labs within 4 weeks of procedure.
Referring Physician:
Phone:
Person filling out form:
Status:
Stat
Routine
Patient Name:
DOB:
Does patient live in nursing home?
Yes
No
(if answer is yes, please use nursing home address & phone # below)
Address:
City:
State:
Zip:
Phone:
Insurance (Primary):
Primary ID #:
Insurance (Secondary):
Secondary ID #:
Auth #:
Can patient consent for themselves?
Yes
No
Does patient need transportation?
Yes
No
Allergies including contrast:
Blood Thinners
(check all that apply)
:
Coumadin/Warfarin
Plavix/Clopidogrel
Xarelto/Eliquis
Apixaban
Referred for Patient Symptoms
Check all that apply.
Peripheral Arterial Disease
Claudication
Rest Pain
Gangrene
Toe Discoloration
Arterial Ulcer-Wound
Venous Disease
Varicose Veins
Venous Stasis Ulcer
DVT
Upper-Lower Extremity Swelling
May-Thurner Syndrome
Dialysis Access Interventions
Fistuagram
Declot
Men's & Women's Health
UFE
PAE
Pain Management
Painful Diabetic Neuropathy
Genicular Artery Embolization (GAE)
Does patient have a wounds?
Yes
No
Does patient need wound care?
Yes
No
Additional Comments:
Referring MD Signature:
Date:
Send By Fax
310.861.8824
or Email:
info@provascularmd.com
Downey, CA
10800 Paramount Blvd,
Ste 406
Downey CA 90241
310.906.2270
Montclair, CA
4950 San Bernardino St
Suite 106,
Montclair, CA 91763
909.850.5800
Apple Valley, CA
16133 Kamana Rd
Apple Valley, CA 92307
760.515.1000
