Expert Vascular & Interventional Care Seamless Patient Referrals

Patient Insurance

Member ID

Group #

Physician Name*

Physician Phone #*

Physician Fax

Patient Name

Patient DOB

Patient Phone #

Diagnosis Code

Physician Notes

Please Include patient demographics and medical records

Physician Notes

Patient Evaluation For:

Patient Evaluation For

Genicular Artery Embolization (GAE) – Osteoarthritis of the knee Plantar Fascia Embolization (PFE) – Plantar Fasciitis Adhesive Capsulitis Embolization (ACE) – Frozen Shoulder Uterine Fibroid Embolization (UFE) – Uterine Fibroids Spinal Cord Stimulation (SCS) – Painful (diabetic) Neuropathy Peripheral Arterial Disease (PAD) – Leg pain/wounds Chronic Venous Insufficiency (CVI) – Leg pain/swelling/wounds Hemorrhoid Artery Embolization (HAE)

Areas We Serve

Physicians, refer your patients to Vascular Centers of Texas for expert, minimally invasive vascular and interventional care. We accept referrals for patients across Houston, Fort Worth, Beaumont, and the greater DFW region. Our streamlined referral process ensures your patients receive the highest quality care.

Fort Worth

Houston

Beaumont

Expert Vascular & Interventional Care Seamless Patient Referrals

Physician Notes

Patient Evaluation For:

Areas We Serve

Fort Worth, TX

Call (817) 767-9909

Houston, TX

Call (281) 710-0310

Beaumont, TX

Call (936) 549-2011

Fort Worth

Houston

Beaumont

Sugar Land

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