PLACE LABEL HERE
CARDIOLOGY OUTPATIENT
ORDERS
Call 678-312-4554 for scheduling
 GWINNETT MEDICAL CENTER
 GWINNETT MEDICAL CENTER-DULUTH
 GWINNETT CARDIAC IMAGING
 GMC SPECIALTY CENTER HAMILTON MILL
GMC to Schedule Patient?  Yes
Patient already scheduled?  Yes
 No
 No
Appointment Date:____________ Time:__________________
GMC to Precert Patient?
 Yes  No
(If yes, copy of insurance card & clinical documentation must be sent with
order)
Patient (Mr/Ms)_____________________________________ SSN: ____________________ DOB: ______________
*Patient daytime phone: ______________________________ *Patient evening phone: ______________________
Allergies: _____________________________________________________________________________________
Medicare:  Yes  No
Precertification number if required: ________________________________________
A note to all physicians: Tests should only be ordered that are medically necessary for the diagnosis, symptoms and/or
treatment. The patient may be billed for tests that are not deemed necessary by payers. Please submit ALL (appropriate)
clinical indications for ALL test(s) ordered.
CLINICAL INFORMATION/SIGNS/SYMPTOMS (NO RULE OUTS)

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EKG
Rhythm Strip
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ICD-9 CODES
_______________
_______________
_______________
24 hr Blood Pressure Monitor
24 hr Holter Monitor
48 hr Holter Monitor
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Exercise Stress Test (ETT)*
Exercise Myocardial Perfusion Imaging Scan (MPI)*
Lexiscan (regadenoson) MPI*
Dobutamine MPI*

Cardiac Positron Emission Tomography (PET)*
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 Carotid Ultrasound
Echocardiogram

Stress Echocardiogram*
 Abdominal Aorta Ultrasound*
Dobutamine Stress Echocardiogram*

Transesophageal Echocardiogram (TEE)*
 Vein Mapping______________________________
Lower Extremity Venous Doppler

__________________________________________
Upper Extremity Venous Doppler
 Graft Surveillance___________________________
Lower Extremity Arterial Doppler

__________________________________________
Upper Extremity Arterial Doppler
 Pseudoaneurysm Compression
Raynaud’s Series

Thoracic Outlet Series
Other Procedures: ______________________________________________________________________________
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*Instructions for patient prep on reverse side of form.
The procedure will not be performed in the absence of the completed form including the appropriate diagnosis and/or ICD-9 code supporting the
ordered procedure. Ordering physicians are responsible for the accuracy of the information provided. Please fax form to 678-312-9736 and
have patient bring this form on the date of service.
Physician (please print): ___________________________________
Physician ID#: _____________________
Physician’s signature: _____________________________________
Date: _____________Time: __________
 Telephone
 Fax
*2-18727*
2
Results to (phone or fax #): _______________________________________________
FORM 2-18727 REV. 03/2015
WHITE: Medical Record
CANARY: Patient
Page 1 of
PLACE LABEL HERE
CARDIOLOGY OUTPATIENT
ORDERS
PREP INSTRUCTIONS
ETT Patients
Exercise MPI Patients
Lexiscan MPI Patients
Stress Echocardiogarm
Dobutamine Stress Echocardiogram
Cardiac PET Patients Only:
 No food or drink except water for 6 hours prior to test.
 No caffeine or caffeine-free products (coffee, tea, cola, chocolate, Mountain Dew, or over-thecounter medications containing caffeine) for 12 hours prior to test.
 Bring a list of all of your home medications with you to your appointment
 May take all home medications EXCEPT: (1) Hold all beta-blocker medications for 24 hours prior to
the test unless otherwise instructed by your physician (2) Hold medications containing theophylline
for 12 hours prior to the test.
Transesophageal Echocardiogram and
Abdominal Aorta Ultrasound Patients Only:
 No food or drink for 12 hours prior to the test.
The Outpatient Center at
Gwinnett Medical Center-Duluth
3805 Pleasant Hill Rd.
Duluth, GA 30096
Gwinnett Cardiac Imaging
a Service of Gwinnett Medical Center
755 Walther Rd, Suite 130
Lawrenceville, GA 30046
Gwinnett Medical Center
1000 Medical Center Boulevard
Lawrenceville, GA 30046
Gwinnett Medical Center–Duluth
3620 Howell Ferry Road
Duluth, GA 30096
GMC Specialty Center
at Hamilton Mill
2108 Teron Trace, Suite 100A
Dacula, GA 30019
For directions to any of our facilities, please call 678-312-4652 or visit our Web site at www.gwinnettmedicalcenter.org
FORM 2-18727 REV. 03/2015
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