Referring Physician Checklist
The following checklist describes the information we require when referring a patient. Please be prepared with this information when you contact us.
Your contact information
Name
Address
Phone Number
Fax Number
Information about your patient
Name
Birthdate
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
Other