Health Provider Referral Tool | New Image-Guided Treatments that Target Blood Clots

We put together this tool for healthcare providers to streamline referrals to the C-TRACT Study. We are dedicated to helping patients with Post-Thrombotic Syndrome (PTS) and are ready to work with you and your patients.

HIPAA Warning

Do not enter identifiable patient information into this form!

Health Provider Referral Form

Is the patient ≥ 18 years of age? *

Yes

Does the patient have post-thrombotic syndrome of at least moderate severity? *

Yes

Is there suspicion for, or documentation of, iliac vein obstruction (complete or partial)? *

Yes

Contact information of health care team member (do NOT enter patient name or information here):

Referring Provider’s Name: *

Health Care Team Member Name *

Health Care Team Member Phone Number

Health Care Team Member Email Address *

This form is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

Please notify your team of the study referral so they can expect a call or e-mail from the C-TRACT Clinical Coordinating Center.

PrintFriendly