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Referal Forms

Lower Extremity Arterial Evaluation

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:


LOWER EXTREMITY ARTERIAL ULTRASOUND:

Ankle-Brachial Index
at rest with excercise


Lower Extremity Arterial Doppler


Reason for the test:
Claudication
Pain in Limb
Lower extremity artery atherosclerosis
Other (please specify)

We appreciate your trust and the opportunity to take care of your patients.