New Patient Referral and Diagnostic Test Order Form

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601 John Street, Suite 100, Kalamazoo, Michigan 49007
269.373.1222 • 800.483.8333 • 269.373.6270 fax
bronsonadvancedcardiac.com
Diagnostic services in office provided by
Bronson Methodist Hospital
Offices in: Kalamazoo • Oshtemo • Battle Creek • Paw Paw • Allegan • Vicksburg
_______________________________________________________________________________________________________________________________________
Douglas J. Wunderly, MD • Joel H. Reinoehl, MD • Christopher Rogers, DO • John F. Schonder, MD • Michael S. Pawlik, DO
Robert A. Williams, DO • Thomas A. Keller, MD • Brett J. Eliuk, DO • Michael A. Pack, DO • Shea E. Hogan, MD
New Patient Referral and Diagnostic Test Order Form
Please complete and fax this form to (269) 384-0273 when ordering tests.
Date: _____________ Contact Person’s Name_____________________ Phone #: ____________________
Requesting Physician: ___________________________________ Fax #: __________________________
PATIENT INFORMATION
Name
Birthdate
Social Security Number
Address
City
State
Zip code
Phone Number
Alternate Phone Number
Patient’s Weight
Primary Insurance Name:
Secondary Insurance Name:
Policy #:
Policy #
Male
Female
Authorization #
If the patient’s insurance requires an authorization, please obtain prior to scheduling appointment.
DIAGNOSTIC TESTS
Echocardiogram:
Cardiolite Stress:
_____ 2D Doppler (Standard Transthoracic
_____ Treadmill-preferred if no contra-indication
Imaging)
_____ Lexiscan-preferred if patient can’t walk
_____ Stress- Treadmill
_____ Dobutamine-only if patient can’t exercise or
_____ Stress- Dobutamine
has lung disease
Diagnosis: _____________________________ Diagnosis: _________________________________
Transesophageal Echocardiogram (TEE)
Graded Exercise Test (stress test):
Diagnosis: _____________________________ Diagnosis: _________________________________
Monitor:
EKG
_____ Event (1-2-3-4 week)
Diagnosis: _________________________________
_____ Holter (24-48 hour)
ABI:
____ ABI
____ ABI Stress
Diagnosis: _____________________________ Diagnosis: _________________________________
Resting MUGA:
Office Use Only:
Diagnosis: _____________________________ Appointment Date:______________ Time: ______
PHYSICIAN CONSULTATION
Please circle one: Consultation
Surgical Clearance
Diagnosis:
Please check preferred physician, if any:
□ Wunderly
□ Schonder
□ Keller
□ Hogan
□ Reinoehl (EP)
□ Pawlik
□ Eliuk
□ Rogers
□ Williams
□ Pack
Has patient seen a previous cardiologist? □ No □ Yes If yes, what physician?_________________
Please send all previous cardiac records and cardiac testing done with this referral.
Office Use Only:
Appointment Date: ___________
Revised 07/13
Time: ______________ Location: _______________________
Fax this form to (269)384-0273
We cannot accept the referral without this form.
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