Get Cardiology Patient Appointmentconsultation Request Form
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How to fill out the cardiology patient appointment consultation request form online
Filling out the cardiology patient appointment consultation request form online is a straightforward process that helps ensure that you provide all necessary information for your consult. This guide will assist you with each section and field of the form for a smooth completion.
Follow the steps to fill out the form correctly and efficiently.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Enter the patient's name and date of birth in the designated fields.
- Input the patient's height and weight, and indicate if they have central line access by selecting 'Yes' or 'No.' If 'Yes,' specify the type.
- Fill in the home and alternate phone numbers, along with the patient's address.
- Provide details about the patient's primary and secondary insurance.
- Select the type of evaluation requested by checking the appropriate box for either a consult with a cardiologist or a procedure.
- For urgent requests, select 'Immediate' and specify the reason for urgency. If routine, select 'Routine.'
- Enter the diagnosis code or indications required for scheduling in the specified field.
- Check all applicable options for echocardiography that are required for the patient.
- Complete the section indicating relevant conditions for the patient by checking the appropriate boxes.
- If applicable, check all necessary peripheral vascular imaging options with required fasting instructions.
- Select the relevant nuclear imaging options, keeping in mind any required preparation.
- Choose the necessary electrocardiography options.
- Fill in the ordering physician's details, including name, phone, and fax.
- Both the ordering physician’s signature and diagnosis/indication must be completed before submission.
- After reviewing everything for accuracy, you can save changes, download, print, or share the form as needed.
Complete your cardiology consultation request form online today to ensure a timely appointment.
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During your first appointment, the cardiology team will take measurements called “vitals.” This may include height, weight, blood pressure, breathing rate, resting heart rate and body temperature. Then your cardiologist will perform a head-to-toe examination of your body with a focus on your heart.
Fill CARDIOLOGY PATIENT APPOINTMENTCONSULTATION REQUEST FORM
Fax this form to the number listed with the test you are ordering. REASON FOR REFERRAL: ❒ Diagnostic Testing Only → ❒ Treadmill ❒ 24h Holter ❒ 48h Holter ❒ 7 Day Holter ❒ ECG. Fax completed form to the Consultation and Referral Services Center at . Please fax form and applicable records to . Important: Fax the following along with this order: Demographic information, recent office note, current medication list. SPECIFIC REASON FOR REFERRAL: □ New □ Re-referral to Dr. ______. Response to your consult request may take up to 72 hrs. Appointment date: Appointment time: Physician name: Location: Insurance referral must be faxed to before the appointment can be confirmed. Use Our Secure Consultation Request Form. Click on the button below: Consultation Request Form.
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