Vascular and Image Guided Specialists

Vascular and Image Guided Specialists

Mecklenburg Radiology Interventional Radiology 1900 Randolph RD Charlotte NC 28207 Suite 602 Clinic (704) 384 ? 9654 after Hours (704) 384 ? 3646 Fax information to: (704) 384 ? 3680

Ryan Aronberg M.D. ? Vishwan Pamarthi ? Jonathan Perry ? Andrew Demmert M.D. (Circle provider)

Date_____/_____/20_____ Patient Name_______________________________________________DOB_______/______/________

Patient Phone # (

) _________-_____________ Referring Clinician ________________________________________

Clinician/Authorized Provider Signature_____________________________________________________________________

Consultation for Venous Disease

Consultation for Arterial Intervention

Non-Healing Ulcer

Dissection

Varicose Veins

Chronic Mesenteric Ischemia

SVC Syndrome

Claudication

DVT/Post Thrombotic System

Critical Limb Ischemia

Leg Swelling /Pain

Non-Healing Ulcer

IVC Filter removal

Peripheral Arterial Disease

Other________________________

Renal Artery Stenosis

Carotid Artery Stenosis

Consultation for Male/Female intervention Subclavian Artery Stenosis

Pelvic Venous Insufficiency

Thoracic Aortic Aneurysm

Lower Extremity Venous Insufficiency Vertebral Artery Stenosis

Symptomatic Uterine Fibroids

Visceral/Peripheral Aneurysm

Varicoceles

Vascular Malformations

Prostate Artery Embolization

Other______________________

Other________________________

Consultation for Pain Intervention Compression Fracture Joint/Facet Injection Celiac Plexus Block Sacral Plexus Block Superior Hypogastric Other __________________________

Consultation for Oncology Intervention Chemoembolization/Radioembolization Portal Vein Embolization Soft Tissue Ablation Renal Ablation/Embolization Pulmonary Ablation Hepatocellular Carcinoma Hepatic Ablation

GI interventions

Other___________________________

BRTO TIPS

Date of Consultation: ________________ @____________

G-J Tube Placement

For below procedures Novant Scheduling can be reached at: (704) 384 ? 4177

Dialysis Evaluation/Intervention Fistulogram and Angioplasty Hemodialysis Catheter Placement Hemodialysis Graft Declot Peritoneal Dialysis Catheter

Gastrointestinal Intervention G Tube Replacement G-J Tube Replacement J Tube Replacement Venous Access

IVC Filter Placement PICC Port Placement/Removal Tunneled Catheter Placement (Permcath, Hickman)

Hepatobiliary Intervention Biliary Stone Removal/Percutaneous Biliary Drainage/Stent Placement Percutaneous Cholecystectomy Tube Percutaneous Transhepatic Cholangiogram (PTC)

Urology Intervention Access/Nephrostomy for Percutaneous Lithotomy Anterograde Nephrostogram GU Stone Retrieval Nephroureteral Stent/ Double J Stent Placement or Conversion Percutaneous Nephrostomy/ Tube Placement Suprapubic Urinary Catheter Placement

Image Guided Access Image Guided Needle Placement Renal/Lung/Liver Biopsy Aspiration/Drain Placement

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