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Patient Name: _________________________DOB: Phone:

Reason for Referral (please tick)Immediate (to ED or same day

appointment)Urgent (within 1 week)

o Acute ischaemic limbo Extensive ilio-femoral DVTo Axillary vein thrombosiso Acute pulmonary embolismo Symptomatic AAA (tenderness or

rapid increase in size)o Asymptomatic AAA ≥8cmo Symptomatic carotid artery stenosis

(Crescendo or multiple TIA  or amaurosis fugax)

o Thrombosed or bleeding AVFo Diabetic foot infection

o Chronic limb ischaemia with rest pain, gangrene or ulceration

o Unprovoked DVTo Recurrent DVTo AAA ≥5cmo Superficial thrombophlebitiso Bleeding varicose veinso Post-op wound breakdowno False aneurysm post interventiono Thoracic aortic aneurysmo Asymptomatic aortic dissectiono Popliteal aneurysm >2cmo Asymptomatic stenosis of the

internal carotid arterySemi-Urgent (within 4 weeks) Routine (more than 4 weeks)

o AAA >3cm and <5cmo Claudicationo Asymptomatic peripheral aneurysmso Malfunctioning AVFo Carotid body tumouro Non-healing lower limb ulcerso Pelvic congestion syndrome

o Varicose veinso Recurrent venous ulcerso Unexplained lower limb oedemao Lymphedemao Arterial-venous malformationo Thoracic outlet syndromeo Subclavian artery stenosiso Hyperhidrosiso Incidental finding of mesenteric or

renal artery stenosis (asymptomatic)o Incidental finding of subclavian

stenosis (asymptomatic)o Other

Clinical Comments

Imaging tests performed :

Referred by:__________________________________________ Phone:

Provider No: ___________________________________________Fax: