Information For Healthcare Professionals

Patient Referral Checklist

The following checklist describes the information we request when referring a patient. Please be prepared with this information when you contact the Cardiovascular Center.


Your contact information

  • Name
  • Address
  • Phone Number
  • Fax Number
  • Email

Information about your patient

  • Name
  • Birth date
  • Address
  • Phone Number
  • Social Security Number
  • Insurance Information

Your patient's complete medical history and records

  • Medical History
  • Surgeries/Procedures
  • Devices: type/settings

Description of your patient's current medications

  • Type(s)
  • Dosages
  • Allergies

Diagnostic test reports plus actual films or tracings

  • Cardiac catheterization: actual film plus report
  • Echocardiogram: actual tape plus report
  • Thallium stress test: actual x-ray film plus report
  • Chest x-ray, CT scans, ultrasounds: x-ray films plus report
  • Electrocardiograms: actual tracings if available
  • Electrophysiology testing: actual tracings and reports


Patient Referral Checklist

INFORMATION FOR HEALTHCARE PROFESSIONALS


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