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Referal Forms

Abdominal Aortic Ultrasound

4D Echo and Vascular Laboratory
28-02 Fair Lawn Ave
Fair Lawn, NJ 07410
Patient’s Name:
Patient’s Date of Birth:
Physician’s Name:
Physicians signature:
Physician’s Tel:
Physician’s Fax:


ABDOMINAL AORTIC ULTRASOUND SCREENING:

Reason for the test:

65 year old or older male with history of smoking


ABDOMINAL AORTIC ULTRASOUND:

Reason for the test:

Abdominal Aortic Aneurysm

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