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Cath Lab/Interventional Radiology Procedure and Non-invasive Cardiology Request Form

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Form Contents

 

Patient Information

SEX *
Please Indicate the Days on which the Patient Receives Dialysis, if Applicable.

Non-Invasive Cardiology:

Keep scrolling for the Interventional Radiology procedures questionnaire.

Echo Procedure
Type of Echo: Use Definity as needed
Special Equipment - PCI
Devices
EP/Ablation:

Interventional/ Neuro IR Department Online Scheduling

Provide the name of the physician who referred the patient to the radiologist.

Provide the name of the physician who referred the patient to the neuroradiologist

Primary Insurance Information Information - All Procedures

If you selected other for primary relationship please enter the relationship here.

Primary Type:

Secondary Insurance Information

If you selected other for primary relationship please enter the relationship here.

Primary Type:

Worker's Compensation Information (if applicable)

Scheduling Information

999-999-9999

Questions? Please call Cath Lab Scheduling 562-602-5124 or 562-602-6704

  • Orders (procedures, Diagnosis, & Doctors' Signatures)
  • H & P within 30 days of procedure date, if not, please update
  • Authorization
  • Demographics/Insurance cards
  • EKG
  • Labs
  • Echocardiogram report
  • CXR report
  • Prescriptions
  • Medication list
  • Device Form
  • Other outside reports, previous bypass surgery, stress test etc. Replace this with a title or description