7/11/07 v3

OUTPATIENT Non-invasive Cardiology Request Form
[All appointment request must be called in to the scheduling # by the Physician Office or Patient]
[Please fax a form for EACH laboratory request]
Laboratory
Scheduling #
Fax #
___Echocardiography
___Transesophageal Echo (TEE)
617-667-3219
617-667-4359
Page TEE Fellow: 617-632-7243 Page ID # 91132
___Stress Non-imaging
617-667-2690
Stress Echo [__Exercise __ Pharmacologic] 617-667-2690
Stress Nuclear [__Exercise __ Pharmacologic] 617-667-2071
___FDG-PET viability
617-667-2071
617-667-1753
617-667-1753
617-667-2185 (also order in CCC)
617-667-2185 (also order in CCC)
___Holter Monitor
___Event Monitor (“King of Hearts”)
617-632-0550
617-632-0550
617-632-0558
617-632-0558
___Cardiac MR
617-667-8555
617-975-5480 (Page 2 required)
Date of Request: _____/______/200________
Patient Name:__________________________ BIDMC MRN or SSN#:_______________________
DOB: ___/____/19____
Age:_____
Gender:
Male
Female
Home phone #: _________________________ Work or Cell phone #: ______________________
Referring Physician:____________________________ Office #: ____________________________
FAX#: ______________________________________ Page #: ______________________________
Additional reports to: _____________________________________________________________
Timing (circle):
Routine
Urgent(<2days)
Special requests (Dates/Site): __________________________________________________
Brief History (if PCM/AICD – include settings):
Medications (for Holter/King of Hearts):
Indication for Study/Question to be answered:
2/14/06 v2.1

OUTPATIENT Non-invasive Cardiology Request Form - CMR
[Page 1 and page 2 requested for Cardiac MR ONLY]
***NOTE: For most CMR examinations, the ordering physician or
PCP (or their offices) must initiate a request for pre-authorization***
Patient rhythm:
___ sinus
____ atrial fibrillation
Height: _______ft ______inchest
___ other
Weight: _______lbs
Insurance Company: _____________________________________________________
Insurance Policy #: _______________________________________________________
Allergies: _______________________________________________________________
* * * * * * * * * * MRI Safety Screening (All items MUST be checked) * * * * * * * * * *
Pacemaker/Permanent pacing leads/Implanted Defibrillator*
Intracranial aneurysm clips* (type: _________________________)
Prosthetic heart valve (type: ______________________________)
Prior coronary artery bypass graft (CABG) (date: ______________)
Coronary stent

Recent intravascular coils, filters or stents (site: _____________)
Implanted mechanical pump*
Ocular (eye) implants*
Shrapnel (anywhere in the body)*
Tattooed eyeliner*

Limb or joint replacement or pinning*
Biostimulator or TENS device *
Eye injury involving metal*











YES
YES
YES
YES
YES

YES
YES
YES
YES
YES

YES
YES
YES

No
No
No
No
No




No
No
No
No
No






No
No
No
If any marked “YES,” – please describe – date of implantation, type of implant, etc.:
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
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