azura surgery center - long beach

Specializing in Dialysis Access Management & Vascular Care

+1 (562) 888-8961

info@southerncaliforniavascular.com
16506 Lakewood Blvd Suite 200,
Bellflower, CA 90706

Monday - Saturday 7:00 - 4:00

OPEN Saturdays - Sunday - CLOSED

+1 (562) 888-8961

info@southerncaliforniavascular.com

16506 Lakewood Blvd Suite 200

Bellflower, CA 90706

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Patient Scheduling Form: Peripheral Artery Disease

Azura Long Beach PAD Scheduling Form

MM slash DD slash YYYY
Patient Name
MM slash DD slash YYYY
Patient Address

PAD Consultation Information

Peripheral Artery Disease Consultation for:
*select all that apply
Slow/Non-Healing Wounds (specify location)
*select all that apply
Referring Clinician Name (please print)

Please Complete the following information:

Competent to sign consent?

Some or all of the following may be required to be faxed to our office: 1.Insurance Cards 2. Pt. Demographic Sheet 3. Medication List 4. Most recent H&P
This field is for validation purposes and should be left unchanged.

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