Provider Referral - Testing Referring Physician/Provider*Referring Practice NameReferring Practice Phone*Contact Email TestingSelect Test(s) to Order ECHO Carotid Ultrasound Lower Extremity Ultrasound/Doppler Stress Test Stress Test TypeExercise Stress TestExercise MPILEXIExercise Stress Test reason/symptomExercise Stress Test timeframe (days/weeks)Exercise MPI reason/symptomExercise MPI timeframe (days/weeks)LEXI reason/symptomLEXI timeframe (days/weeks)ECHO reason/symptomECHO timeframe (days/weeks)Carotid US reason/symptomCarotid US timeframe (days/weeks)Lower Extremity US reason/symptomLower Extremity US timeframe (days/weeks)Patient InfoPatient Name* First Last Patient Phone*Date of Birth* Insurance InfoPolicy Holder Name First Last Primary Insurance CarrierPrimary Insurance Policy #Group #Secondary Insurance CarrierSecondary Insurance Policy #Group #Reason for ReferralCardiologist ChoiceFirst AvailableAyalaBajwaBhoopalamKorpasMartinMentzerNassNetzRundlettAdditional Information
