Physician Referral - Fax Cover Sheet

心脏和血管 复苏 Checklist
For Procedures Scheduled in Cath Lab
And Invasive Radiology

传真:706/774 - 8910
电话:706/774 - 3181

病人's Name: _________________________________________________________

Physician: ______________________________________________________________

Date of Scheduled Procedure: _________________ Time of Arrival to CVR __________

The following information is required to be on record when a patient is scheduled for a procedure in our area (Cardiac Cath, PTCA, 支架, Invasive Radiological Procedures). Please ensure that all necessary information is faxed to the Cardio血管 复苏 Room prior to the patient's scheduled procedure.

[ ] History and 物理 dictated within the past 30 days with update note

[ ] Signed Consent form

[ ] Labwork: CBC, BMP, PT within the past 7 days

[ ] EKG with the past 7 days Optional



Name of office contact for further information :__________________________


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