NOTE: In compliance with the Order/Schedule Form Universal Protocol for Wrong Site Surgery, all areas highlighted in BLUE must be completed in full by the referrer. Accredited by The Joint Commission Pacific Interventional Vascular Access Center • 6076 Bristol Parkway, Suite 108 • Culver City, CA 90230 Tel: 310.348.9604 • Fax: 310.338.1219 □ Mason Weiss, MD □ Spencer Brown, MD □ Marius Saines, MD Patient Name □ Ali Golshan, MD Date of Birth Patient Address City State Home # ( ) Zip Office # ( ) Cell # ( ) Patient Allergies Patient Insurance Authorization Referring Physician Physician Phone # ( ) Specialty Relevant Medical Conditions Acute Issue for Referral VASCULAR ULTRASOUND SERVICES Location: □ Lower Extremity □ Upper Extremity □ Right / □ Left / □ Bilateral □ Other Desired Study: □ Duplex Ultrasound Arterial/ABI □ Duplex Ultrasound Venous □ Abdominal Aortic Duplex □ Evaluate for Deep Vein Thrombosis □ Carotid Duplex PERIPHERAL ARTERIAL DISEASE/PAD □ PAD Consultation □ Endovascular Repair □ Access: 嘷 Right/ 嘷 Left 嘷 Antegrade 嘷 Retrograde □ Lesion Location: □ Desired Procedure: 嘷 Revascularization 嘷 PTA 嘷 Stent 嘷 Atherectomy 嘷 Cryoplasty 嘷 Other Indication: 嘷 Numbness and Tingling 嘷 Claudication (pain with excercise) 嘷 Rest Pain (pain without excercise or night) 嘷 Open Sore / Ulcer (non-healing) 嘷 Other IVC FILTER □ IVC Filter Placement □ IVC Filter Retrieval PERIPHERAL VENOUS DISEASE / CHRONIC VENOUS INSUFFICIENCY (CVI) □ Location: □ Right/ □ Left/ □ Bilateral □ Upper Extremity / □ Lower Extremity / □ Other □ Desired Procedure: □ Diagnosis / Management of Varicose Veins Indication: { □ Pain □ Restless Leg □ Diagnosis / Management of Deep Vein Thrombosis □ Tired/Achy Legs □ Ulceration □ Swelling □ Varicose Veins □ Skin Discoloration □ Other RENAL ARTERIOGRAPHY ONCOLOGY □ Renovascular Occlusive Disease / Renal Artery Stenosis □ Port Placement/Removal □ Hypertension □ Leg Pain Protocol (Arterial & Venous Duplex Ultrasound) □ PICC Line Placement □ Progressive Renal Insufficiency WOMEN’S HEALTH □ Uterine Fibroid Embolization Indications: □ Pain □ □ Heavy Menses HSG □ Bloating □ □ Infertility Pelvic Congestion Treatment □ Other TO SCHEDULE PLEASE CALL OR FAX THIS FORM WITH A COPY OF THE FOLLOWING: 1. Prescription for Procedure 2. Insurance Cards 3. Pt. Demographic Sheet 4. Medication List 5. Most recent H&P ©2014. This form is copyright protected and may not be reproduced in any manner without our permission. □ Chemoembolization 6076 Bristol Parkway, Suite 108 • Culver City, California 90230 • Tel: 310.348.9604 • Fax: 310.338.1219 Directions: From the South on 405: 1. 2. 3. 4. 5. Head north on 405 Freeway Exit 49B Sepulveda Blvd toward Slauson Ave Turn right onto Green Valley Circle Take the 2nd left onto Bristol Pkwy Destination will be on your right From the North on 405: 1. 2. 3. 4. 5. 6. 405 south towards LAX Airports/Long beach Take exit 50B towards Slauson Ave Merge onto 90E Slight right onto W Slauson Ave 1st right onto Bristol Pkwy Destination will be on your left ©2014. This form is copyright protected and may not be reproduced in any manner without our permission. SPDIVMD0413-PV