Submit a Referral Online

Complete the form below, sign at the bottom, and click Send Referral — it goes straight to our office. Fields marked * are required.

Patient Information

Patient Name *

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Patient DOB *

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Contact #

Alternate #

Insurance

ID #

Group #

Referring Provider Information

Provider Name *

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Contact #

Clinic Name

Vascular Imaging / Vein Center

Peripheral Arterial

ABI (Ankle-Brachial Index), resting TBI (Toe-Brachial Index)

Peripheral Venous Testing

Lower Extremity Venous Duplex (Venous Insufficiency Evaluation) Lower Extremity Venous Duplex – DVT, Bilateral Lower Extremity Venous Duplex – DVT, Unilateral, RIGHT Lower Extremity Venous Duplex – DVT, Unilateral, LEFT

Priority

Routine STAT

Indications / Diagnoses

Skin Ulcer (new, recurrent, or chronic non-healing) History of DVT Known Post-Thrombotic Syndrome Recurrent Cellulitis Lymphedema Unexplained Leg Heaviness Restless Leg Syndrome Unexplained Leg Cramping Varicose Veins Unexplained Leg Pain Unexplained Numbness Skin Problems (discoloration, redness, rash)

Other Diagnosis

Referring Provider Signature

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Date *

Signature *

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I am the referring provider or authorized staff, and I certify that the information above is accurate to the best of my knowledge.

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By submitting, this referral is sent securely to Lone Star Vein Clinic. Prefer another method? Fax to (512) 677-7780 or email info@lonestarvein.com.

✅ Referral Received

Thank you for referring your patient to Lone Star Vein Clinic. Our team will reach out to schedule. If you need to speak with us, call (512) 677-7780.