PHYSICIAN ORDER FORM - PARK AVENUE MEDICINE & SURGERY - ENDOvASCULAR tREATMENT PATIENT EDUCATIONAL MATERIAL REQUEST

Patient Name *

First Name

Last Name

Phone

(###)

###

####

Date of Birth: (ex: Month, Day, Year: January, 01, 1990)

MM

DD

YYYY

Please Contact Patient for the Following:

Enroll in Patient Ambassador Program (to connect with another patient who has device)

Answer Technical and Engineering Questions about Device.

Treatment / Diagnosis:

VENASEAL - Vascular Insufficiency

ENDOVENOUS RFA (RADIOFREQUENCY ABLATION) - Vascular Insufficiency