Referring Physician Checklist

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

To Schedule:

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

For Appointment:

Your patient's complete Medical History and Records

• Medical History
• Surgeries/Procedures including Operative Reports
• Devices: type/settings

Description of your patient's current Medications

• Type(s)
• Dosages
• Allergies

Diagnostic Test reports plus actual films or tracings – as they apply to the patient:

• 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
• Vascular laboratory: actual ultrasound images, pressure tracings and reports
• PET scans, bone scans, films plus reports
• Pulmonary evaluation consultation plus pulmonary functions, and ABG reports
• Procedures - EGD, Colonoscopy, EUS, Bronchoscopy, CT guided biopsy reports  plus pathology and slides for review
• Other

    

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