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Vascular Laboratory

Vascular Lab Exam Referral Form

The form below is one of two forms that must be completed to request a vascular exam. Please complete the form below, then proceed to the MD Uniform Referral Request form.

If this is an emergency, please call the vascular lab to schedule an emergency exam. For more information or to schedule an emergency exam, please call 410-550-VLAB (8522).

Fields marked with * are required.
 
Patient Demographic Information
Below, please paste in the patient’s addressograph label.
 
Referring Physician Information
 
Insurance Information
If no secondary insurance, please enter "n/a."
If no secondary insurance, please enter "n/a."
 
Indication for Test Request (proper indication required)
 
Test Request (please check appropriate box)
 
Arterial test requested:
 
Cerebrovascular test requested:
 
Venous test requested:
 
Abdominal test requested:
 
Dialysis graft test requested:
 
 
 

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4940 Eastern Avenue. Baltimore, Maryland 21224. 410.550.0100