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
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
INFORMATION FOR HEALTHCARE PROFESSIONALS
