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 TypeRoutine Treadmill Stress EchoRoutine TreadmillLexiscan CardioliteTreadmill CardioliteDoubutamine Stress EchoRoutine Treadmill Stress Echo reason/symptomRoutine Treadmill Stress Echo timeframe (days/weeks)Routine Treadmill reason/symptomRoutine Treadmill timeframe (days/weeks)Lexiscan Cardiolite reason/symptomLexiscan Cardiolite timeframe (days/weeks)Treadmill Cardiolite reason/symptomTreadmill Cardiolite timeframe (days/weeks)Doubutamine Stress Echo reason/symptomDoubutamine Stress Echo 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* Date Format: MM slash DD slash YYYY Insurance InfoPolicy Holder Name First Last Primary Insurance CarrierPrimary Insurance Policy #Group #Secondary Insurance CarrierSecondary Insurance Policy #Group #Reason for ReferralCardiologist ChoiceFirst AvailableAyalaBajwaBhoopalamKoduriKorpasMartinMentzerNassNetzRundlettAdditional Information
