Provider Referral - Testing

Referring Physician/Provider*
Referring Practice Name
Referring Practice Phone*
Contact Email
Testing
Upload Order
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 Info
Patient Name*
First Last
Patient Phone*
Date of Birth*
Date Format: MM slash DD slash YYYY
Insurance Info
Policy Holder Name
First Last
Primary Insurance Carrier
Primary Insurance Policy #
Group #
Secondary Insurance Carrier
Secondary Insurance Policy #
Group #
Reason for Referral
Cardiologist Choice
Additional Information

COVID -19 OFFICE POLICIES

1. To keep our patients and staff safe all patients and guests are REQUIRED TO WEAR A MASK. Please bring your own mask to the appointment and be prepared to wear the mask at all times. If you do not have a mask one will be provided for you subject to availability. Anyone who refuses to wear a mask will not be permitted in the office or clinics. Thank you for your help with this.

2. SCREENING IS REQUIRED. Every person entering our facility will be screened for COVID-19 symptoms and fever, along with questions regarding any recent exposures or travel history. Anyone refusing screening will be denied admittance to our facility.

3. Only ONE GUEST may accompany a patient. Guests must adhere to the same guidelines as patients.

4. Unauthorized vendors, sales reps, etc. are prohibited until at least October 1, 2020. To speak with our staff please call 402-413-6363.

5. Experiencing symptoms or have a known COVID-19 exposure? Please call our office at 402-413-6363 to reschedule your appointment. Thank you for your help in keeping everyone healthy and safe during this time.

Provider Referral - Testing

Testing

Patient Info

Insurance Info

COVID -19 OFFICE POLICIES