Kamran Goudarzi, MD  v  Hormoze Goudarzi, MD


1721 New Hanover Medical Park Dr.
Wilmington, NC 28403


v Phone (910) 763-6571 v Fax (910) 763-9971 v

v    Kamran Goudarzi, M.D., F.I.C.S., F.A.C.S.    v    Hormoze Goudarzi, MD, F.R.C.S, F.A.C.S.    v
1721 New Hanover Medical Park Dr.
Wilmington, NC  28401
(910) 763-6571

Contact Us

Notice of Privacy Practice

Copyright 2008.  BITSnBYTES. All rights reserved.

 

P H Y S I C I A N S   O N L Y
Vascular Lab Referral

Please complete the necessary information and submit to our office.  A representative from our office will contact the patient to set up their appointment.  Upon completion of this form, you will be routed to a page with general information, special instructions, and directions for the patient.  Please make sure the patient receives a copy of this form.  If you have immediate questions, please contact our office at (910) 763-6571.
Patient Name:
Mailing Address:
City:
State:
Zip:
Home Phone:
Work Phone:
Cell Phone:
Date of Birth:
Social Security Number:
Referring Physician:
Once submitted, this will be accepted and acknowledged as an electronic signature of the referring physician.
Number to call report to:
Reason for Exam
 Prior Films?:  Yes       No
If so, where?:
Exam(s) Requested:  AB Complete (76700)
AB US Limited (76705)
Aorta Complete (93878)
Breast US (76645)
Carotid US (93880)
Arterial Lower Ext Bi Lat / Uni / ABI (93922) *
Arterial Lower Ext Bi Lat / Uni (93925) *
Arterial Lower Ext Bi Lat Duplex (93926)
Arterial Upper Ext Bi Lat / Uni (93930) *
Arterial Upper Ext Bi Lat Duplex (93931)
GB - Liver or Pancreas (76705)
US Extremity Non Vascular (76880)
US Pelvic Limited (76857)
US Scrotum/Testicular (76870)
US Thyroid (76536)
US Extremity Veins, Non-Invasive; Complete B Study; Mapping (93965) *
Duplex Extremity Veins; w/ Comp, Complete B Study (93970) *
Duplex Extremity Veins; Unilateral/Limited Study (93971) *
Segmental Pressures - In Main Office (93923)
Renal U/S (76770)
PAD Screening
Varicose Vein Consult (FIRST VV)
Vascular Wellness Screening
Additional Comments: Please specify instructions for exams above with *.  Also feel free to include any additional information you feel necessary.
 

v    Kamran Goudarzi, M.D., F.I.C.S., F.A.C.S.    v    Hormoze Goudarzi, MD, F.R.C.S, F.A.C.S.    v
1721 New Hanover Medical Park Dr.
Wilmington, NC  28401
(910) 763-6571

Contact Us

Notice of Privacy Practice

Copyright 2008.  BITSnBYTES. All rights reserved.