Peripheral Arterial Occlusive Disease Risk modification Clinic 


Referrals from vascular surgery Tallaght Hospital ONLY. All other referrals should be submitted via the Vascular Surgery Clinic pathway.

Please print a copy of the Intermittent Claudication advice sheet and Peripheral Arterial Rehabilitation clinic Information leaflet and give to the patients who are being referred.


Patient name*
Address*
MRN*
Date of birth:*
 / 
 / 
Contact phone number:*
Co-Morbidity
Vascular status
Most proximal level of disease:
Claudication distance (m, estimated)
Summary

Referrer details

Name:*
E-mail:*

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