CEREBROVASCULAR	Patient Details	
<Cerebrovascular>	Name:<PtName>	
	DOB: <PtDoB>	
LEG - ARTERIAL	Addresss:<PtAddress>	
<Leg - Arterial>		
	Examination Required	
	Enter Text

	
LEG - VENOUS		
<Leg - Venous>	Test Urgency  <Examination urgency>	
		
ARM - ARTERIAL	Reason for Examination	
<Arm - Arterial>	

		
ARM - VENOUS		
<Arm- Venous>	Copy to	
		
ABDOMINAL		
<Abdominal>		
	Referring Doctor                             Date: <TodaysDate>	
	Name: <DrName>	
	Address: <DrAddress>	
	Provider Number: <DrProviderNo>	
*Fasting instructions required unless diabetic.		

HAMILTON 116 Everton Street NSW 2303
GATESHEAD Suite 2, Level 1 Specialist Medical Centre, Lake Macquarie Private Hospital, Sydney Street 2290
EAST MAITLAND Suite 14b, Level 2 Specialist Medical Centre 2, Maitland Private Hospital, Chisholm Street NSW 2323
TORONTO Suite 4, Medical Centre 2, Toronto Private Hospital, Excelsior Parade NSW 2283
NELSON BAY 33 Stockton Street, Nelson Bay, NSW 2315

APPOINTMENT Date. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  Time. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 
OPENING HOURS Monday to Friday: 9am to 5pm
We appreciate you have a choice. Thank you for choosing The Vascular Centre.

THE VASCULAR CENTRE
p: 02 4920 8277 | f: 02 4942 3199 | e: info@thevascularcentre.com.au | www.thevascularcentre.com.au
HAMILTON 116 Everton Street NSW 2303
GATESHEAD Suite 2, Level 1 Specialist Medical Centre, Lake Macquarie Private Hospital, Sydney Street 2290
EAST MAITLAND Suite 14b, Level 2 Specialist Medical Centre 2, Maitland Private Hospital, Chisholm Street NSW 2323
TORONTO Suite 4, Medical Centre 2, Toronto Private Hospital, Excelsior Parade NSW 2283
NELSON BAY 33 Stockton St, Nelson Bay, NSW 2315
ABN 35 975 837 147