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Patient Name:
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Date of Study:
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Select Reason for Study:
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Type - Reason for Study:
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Examination:
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Indications:
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Right Leg
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Left Leg
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Right Leg Greater saphenous/CFV
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Left Leg Greater saphenous/CFV
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Right Leg CFV
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Left Leg CFV
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Right Leg SFV Proximal
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Left Leg SFV Proximal
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Right Leg SFV Mid
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Left Leg SFV Mid
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Right Leg SFV Distal
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Left Leg SFV Distal
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Right Leg Popliteal
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Left Leg Popliteal
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Right Leg Lesser Saphenous/Pop Junction
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Left Leg Lesser Saphenous/Pop Junction
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Right Leg Saphenous Proximal
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Left Leg Saphenous Proximal
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Right Leg Saphenous Mid
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Left Leg Saphenous Mid
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Right Leg Saphenous Distal
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Left Leg Saphenous Distal
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Physician Comment:
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Impression:
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Lower Venous System
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Referral Sautation
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