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This form may be submitted online or downloaded and faxed to (407) 650-1329 (Downtown office), (407) 370-5859 (Sand Lake), or (407) 290-2118 (Health Central).

Diagnostic Request Form
ORLANDO HEART CENTER
Downtown Phone (407) 650-1389
Sand Lake Phone (407) 370-5858
Health Central Phone (407) 290-3050		 Downtown Fax (407) 650-1329
Sand Lake Fax (407) 370-5859
Health Central Fax (407) 290-2118
***** ALL information MUST be completed for appointment to be scheduled *****


This Section MUST Be Completed:

PATIENT NAME: (required)
DOB: (required)  
SOCIAL SEC #:
HOME PHONE: (required)  
WORK PHONE:  
ORDERING DOCTOR:
ORDERING DR PHONE:
 		ORDERING DR FAX:
 		 
INSURANCE:
TYPE OF INSURANCE:  HMO   PPO   OTHER
AUTHORIZATION #:
# VISITS: EXPIRES:  
PREFERRED APPOINTMENT:  DAY:   TIME:
PREFERRED LOCATION: SANDLAKE OFFICE
ORDERING DR OFFICE
GORE ST OFFICE
HEALTH CENTRAL OFFICE
 
DIABETIC? Yes  No   WEIGHT:    

ASPIRIN? Yes  No     COUMADIN? Yes  No  

ALLERGIES:

 
OFFICE CONSULTATION:   NEW PATIENT   ESTABLISHED PATIENT
Abnormal EKG Dizziness Mitral Stenosis  
Angina Dyspnea / SOB Palpitations  
Atrial Fibrillation Heart Murmur Syncope  
Chest Pain Mitral Valve Disease Tachycardia  
Other: (Explain Below)  
   

TREADMILL STRESS TEST
Abnormal EKG Dyspnea / SOB Aortic Valve Disorder  
Heart Block Arrhythmia Heart Murmur  
Athersclerosis Mitral Valve Disorders Atrial Fibrillation  
Myocardial Infarction Bradycardia Palpitations  
CAD Pulmonary Hypertension Chest Pain  
Tachycardia CHF Ventric Fibrilation/Flutter  
       
DUAL ISOTOPE GATED SPECT (THALLIUM)     ADENOSINE STRESS TEST
DOBUTAMINE STRESS TEST    
Abnormal EKG Left Bundle Branch Block Angina  
Mitral Valve Disorder Athersclerosis Myocardial Ischemia Chronic  
Atrial Fibrillation Old MI Congestive Hrt Failure  
Right Bundle Branch Block Ischemic Heart    
       
HOLTER MONITOR
Angina Atrial Flutter Mitral Valve Disorder  
Syncope Arrhythmia Bradycardia  
Palpitations Tachycardia ASHD  
Cardiomegaly Premature Beats Ventricular Fibrillation  
Atrial Fibrillation Cardiomyopathy PVCs  
       
EVENT MONITOR      
Dizziness Palpitations Syncope  
       
2D ECHOCARDIOGRAM WITH DOPPLER
Angina Mitral Stenosis Aortic Valve Disorder  
Mitral Valve Disease ASHD Old MI  
Chest Pressure Pulmonary Valve Disorder CHF  
Syncope Congenital Heart Disease Tricuspid Valve Disorder  
Heart Murmur      
       
VENOUS DOPPLER CAROTID DOPPLER ARTERIAL DOPPLER  
Edema Bruits Atherosclerosis  
Limb Pain Carotid Artery Disease Injury to Blood Vessels  
Limb Swelling TIA/Trans Iscemic Attack PVD/Claudication  
Thrombophlebitis/Phlebitis   Ulcer Lower Limb  
Varicose Veins      
Venous Insufficiency      

At Orlando Heart Center we understand privacy is very important to our patients.
Please feel free to review our privacy policy at any time.

 
The material provided on this site is for general information purposes only. It is not intended to be used as medical advice and does not substitute for proper consultation with trained medical personnel.
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