Lab/Imaging/ECG Request

LABS, IMAGING, PT EDUCATION
You may select multiple tests from one category however, if you are ordering tests from more than one category, you will need to complete a separate form for each category.
Today's Date*

MonthDayYear
Patient ID #
Patient Information
Patient Name:*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Patient Sex*
Height
Weight
Call Patient to Schedule?*

YesNo
Patient Phone*
Pregnant?*

YesNo
Diabetic?*

YesNo
Allergies*

NoneLatexContrastIodineOther
Fasting?*

YesNo
Billing
Please Select:*

Self-PayInsuranceBill Clinic
Insurance/Plan*
Member # / ID*
Authorization #
Authorization Valid From:

MonthDayYear
To:

MonthDayYear
Ordering Provider
Full Name of Provider*

PrefixFirst NameLast Name
Provider Signature*

Clear
Date Signed*

MonthDayYear
NPI # (if First Time Ordering)
Clinician Phone*
For internal My Heart Spark P.C. administrative use and to send the provider a copy of their request.
Name of Clinic*
Clinic Contact*
Clinic Fax *
Exam(s) Ordered
Please select from the test category you are ordering:*

LabECG, Holter, Event MonitorOther ImagingPatient EducationOther
LABS | Please select from the following options:*

Comprehensive Chemistry PanelLFTsTSH ReflexLipid PanelMeasured LDLCKCKMBHigh Sensitivity Troponin SingleHgbA1CPotassiumCreatinineLipoprotein ACBCFerritinHIVLight ChainsMonoclonal Protein StudySPEPUPEPImmunofixationPYP ScanOther
ECG | Please select from the following options:*

12-LeadOther
HOLTER OR EVENT MONITOR | Please select from the following options:*

12-LeadHolter Monitor (24 hours)Holter Monitor (48 hours if available, otherwise 24 hours)Holter Monitor (72 hours if available, otherwise 24 hours)Event Monitor (Ziopatch if available and co-pay is acceptable to patient)Other
OTHER IMAGING | Please select from the following options:*

Transthoracic Echocardiogram (with Strain if EF WNL)Hemodynamic Stress Echo with BicycleChest CT without Contrast for Calcium ScanCoronary CT with Angiography and 3D FFR with ReconstructionCardiac MRIStress Cardiac MRINuclear Stress Test (SPECT, Sestamibi)Cardiopulmonary Stress TestCardiopulmonary Stress Test with EchoChest x-rayOther
PATIENT EDUCATION| Please select from the following options:*

DietitianGenetic Counselor, and testing if applicableDiabetes EducatorHeart Failure EducationOther
Indication/Reason for Test
Please provide the indication/reason for requesting the test(s):*
Additional Comments/Instructions*
Testing/Patient Education Facility
Thank you so much for your help! We appreciate the collaboration.

Please reach out to us at appointments@myheartspark.com if we have ordered any duplicates or if you have any questions about our request. Please send results to us using our secure fax line 414-261-7671, or upload results via our detailed HIPAA compliant Lab | Imaging | Patient Education Results Upload form.
Should be Empty:

LABS, IMAGING, PT EDUCATION

Patient Information

Billing

Ordering Provider

Exam(s) Ordered

Indication/Reason for Test

Testing/Patient Education Facility