| Referring Physician: |
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| Urgency |
RoutineASAPURGENT (please telephone)
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| First Name: |
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| Last Name: |
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| Daytime Phone: |
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| Evening Phone: |
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| Problem / Diagnosis:: |
Chest Pain
Hypertension/Lipids
Arrhythmia
Fainting/Near Fainting
CHF
Shortness of Breath
Claudication
Non Healing Wounds
Peripheral Artery Disease
Venous Disease
Valvular Heart Disease (murmur)
Abnormal ECG
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Consultation Type
|
ConsultationTest only
Test only with formal consult when significantly abnormal test result |
Follow-up
|
Follow-up Visit |
| Electrocardiography |
12 Lead Electrocardiogram (12 Lead ECG)
24 Hour Ambulatory Electrocardiography (Holter Monitor)
Event/Loop Monitor (2-4 week Holter Monitor with patient triggered events and automatic monitoring)
Tilt Table |
| Ultrasound |
Echocardiogram
Carotid Imaging
Venous Leg Scan (for DVT)Rt LegLt Leg
Both Legs
Venous Leg Scan (for venous insufficiency)Rt LegLt Leg
Both Legs
Renal Ultrasound
Ankle/Brachial Index
Abdominal Aorta (for Abdominal Aortic Aneurysm) |
Stress Testing
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Treadmill Stress Test
Treadmill Stress Echocardiogram (Exercise Stress Echo Test)
Pharmacologic Stress Echocardiogram (Dobutamine Stress Echo Test)
Treadmill Nuclear Stress Test (Nuclear Exercise Myocardial Perfusion Stress Test)
Pharmacologic Nuclear Stress Test (Adenosine/Dobutamine Nuclear Myocardial Perfusion Stress Test) |
Pacemaker Check
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Pacemaker Evaluation and Reprogramming |
Defibrillator Check
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Defibrillator Evaluation and Reprogramming |
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