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Page 1: Patient Name DOB *Why are we seeing the patient? Please

Phone: 574-272-5347 Fax: 574-272-8617

Patient Name___________________________________ DOB__________________

*Why are we seeing the patient? Please check all that may apply:o Venous Insufficiency/Varicose Veino Peripheral Vascular Diseaseo Abdominal Aortic Aneurysmo Carotid Artery Diseaseo Kyphoplasty/Vetebroplasty **(Please order MRI of Spine level specific)o Yttrium (Y-90)o Trans-arterial Chemoembolization **(Please order MRI of Abdomen with/without

contrast)o Dialysis Access (AV Fistula or Graft)o Inferior Vena Cava Filter (IVC)o Uterine Fibroid Embolization**(Please order MRI of Pelvis with/without contrast)o OTHER____________________________________________________________

Please return this page and include the following patient information:

• Recent office notes• Demographics• Any recent imaging• Insurance information – Card copies if possible

Ordering Physician Signature___________________________________

Ordering Physician ___________________________________ Printed Name

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