Referral for Outpatient Clinical Evaluation, Treatment Planning and Scheduling 1220 West Ash Street Suite B Windsor, CO 80550 NoCo Clinic Phone: 303.930.2849 NoCo Clinic Fax: 720.493.3787 RIAEndovascular.com

Referral to: l First Available l Specific Physician (Name) ______

Patient Name ______Patient Phone ______DOB ______Please FAX Diagnosis ______insurance Notes ______information and ______appropriate Ordering Physician’s Name ______clinical notes to (Please print) 720.493.3787 Signature ______Phone ______

PROCEDURES

Venous Interventions Interventional Oncology Liver Interventions l Venous Insufficiency l Regional Liver Cancer - Primary, l Biliary Drainage & Stent Placement l Varicose/Spider Veins Metastatic l Cholecystostomy Drain (Gall Bladder) Sclerotherapy, Foam, Endovenous Laser Radioembolization, Chemoembolization, l Transjugular Intrahepatic Porto-systemic Ablation, Radiofrequency Ablation, Nanoknife Shunt (TIPS) Ambulatory Phlebectomy, Cosmetic l Local Tumors - Liver, Lung, Renal, Bone, l Deep Vein Thrombosis Adrenal, Prostate Peritoneal Drainage Cryoablation, Radiofrequency, Microwave l Paracentesis Arterial Interventions Ablation, Nanoknife l Tunneled Peritoneal Catheter Placement l Peripheral Artery Disease l Infusion Port Angiography, Angioplasty, Stenting Placement, Removal Pleural Drainage l Abdominal Aortic Aneurysm l Thoracentesis Stent Graft Spinal Procedures l Aspira®/PleurX® Tunneled Pleural Catheter l Renal and Mesenteric Artery Stenosis l Vertebral Body Fracture Angioplasty, Stenting Kyphoplasty, Spine Jack, Vertebroplasty Vascular Access l Splenic Embolization l Sacral Insufficiency Fracture l Arteriovenous Fistulagram Sacral Vertebroplasty l Dialysis Access – Catheters Gynecological Interventions l Epidural Steroid Injection l Tunneled Central Line l Pelvic Vein Congestion l Ablation for Facet Pain l Peripherally Inserted Central Catheter (PICC) Ovarian Vein Embolization Placement, Removal l Uterine Fibroids Blood Clots Uterine Fibroid Embolization l Chronic Venous Reconstruction Osteoarthritis Treatment l Stenting for May-Thurner Syndrome l Geniculate Nerve Ablation Urological Interventions l Catheter-Directed Thrombolysis & l Geniculate Artery Embolization l Enlarged Prostate Thrombectomy Prostate Artery Embolization l Inferior Vena Cava (IVC) Filter Drain Care l Varicocele Placement, Removal l Abscess Drain Varicocele Embolization l Pulmonary Thromboembolectomy Placement, Maintenance l Nephrostomy Tubes l Lymphocele Drain Placement, Exchange, Removal Musculoskeletal Intervention and Placement, Sclerosing l Ureteral Stents Cancer-Related Pain Internalize Nephrostomy Tube l Ablation of Painful and Radiation Other Interventional Procedures ______l Access for Stone Removal Resistant Bone Tumors l l Pelvic Osteoplasty and Stabilization l Palliative Neurolysis l Interventional Radiology Consult

Thank you for referring to Northern Colorado RIA Endovascular. RIAE-857 4/29/20