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: _________________________________________________________
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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We hope your experience with us is an excellent one.