imaging center test request


Patient's Name
Date of Birth
Address (City, State, Zip)
Social Security No.	- -
Home Phone
Work Phone
Patient's Diagnosis
Type of Test
Insurance
Pre-cert?	Yes No
Ordering Physician
Office Phone
Office Fax

CARDIAC IMAGING STUDIES
Echocardiography - Dx
	Doppler Echo
	Exercise Stress Echo
	Pharmacologic Stress Echo
	"Bubble" Study

Nuclear Cardiology - Dx
	Exercise Nuclear Stress Test *
	Pharmacologic Nuclear Stress Test *
	* All Blue Cross/Blue Shield Plans need authorization from the ordering physician.

Non-Imaging Stress Tests - Dx
	Treadmill Exercise STress Test

Holter/Event Monitoring - Dx
	Holter Monitor
	T-Wave Altemans 24-Hour Other

VASCULAR STUDIES
Arterial - Dx
	Lower Extremity
	Upper Extremity
	Thoracic Outlet Syndrome
	API/ABI
	AVF Steal Study
	Digital Waveform
	Duplex Graft Velocity
	Vasospasm/Raynaud's Upper Lower

Venous - Dx
	Venous Dopper Duplex Right Left Bilateral Upper Lower
	AV Fistula
	Vein Mapping

Abdominal Imaging - Dx	NPO After Midnight
	Aorta
	Messenteric/SMA
	Renals

Cerebrovascular - Dx
	Carotid/Vertebral
	Subclavian Steal Right Left Bilateral
Lipid Screening - Dx 272.4
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