Provider Referral - Testing Referring Physician/Provider* Referring Practice Name Referring Practice Phone*Contact Email TestingUpload OrderMax. file size: 300 MB.Select Test(s) to Order ECHO Carotid Ultrasound Lower Extremity Ultrasound/Doppler Stress Test Stress Test Type Routine Treadmill Stress Echo Routine Treadmill Lexiscan Cardiolite Treadmill Cardiolite Doubutamine Stress Echo Routine Treadmill Stress Echo reason/symptom Routine Treadmill Stress Echo timeframe (days/weeks) Routine Treadmill reason/symptom Routine Treadmill timeframe (days/weeks) Lexiscan Cardiolite reason/symptom Lexiscan Cardiolite timeframe (days/weeks) Treadmill Cardiolite reason/symptom Treadmill Cardiolite timeframe (days/weeks) Doubutamine Stress Echo reason/symptom Doubutamine Stress Echo timeframe (days/weeks) ECHO reason/symptom ECHO timeframe (days/weeks) Carotid US reason/symptom Carotid US timeframe (days/weeks) Lower Extremity US reason/symptom Lower Extremity US timeframe (days/weeks) Patient InfoPatient Name* First Last Patient Phone*Date of Birth* MM slash DD slash YYYY Insurance InfoPolicy Holder Name First Last Primary Insurance Carrier Primary Insurance Policy # Group # Secondary Insurance Carrier Secondary Insurance Policy # Group # Reason for Referral Cardiologist ChoiceFirst AvailableAyalaBajwaBhoopalamKoduriKorpasMartinMentzerNassNetzRundlettAdditional Information
