Exam Room Referrals
Name
First Name
Last Name
Followup:
One
Two
Three
Four
Five
Six
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Week(s)
Month(s)
Year(s)
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PRN: Patient will call us if they need us.
PRN: Patient will call us after IMAGING is completed.
PRN: Patient will call us after PT is completed.
PRN: Patient will get us imaging records and then we will contact them.
PRN: Patients WC case manager will contact us once the next step is done.
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with Dr. DAgostino
with Amanda Crowley, NP
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Other
The date and time of your next appointment is:
________________________________
Other Information:
EMAIL us at Info@Seaside-Spine.com when you are ready for the next step in your care.
Please review the packet of information you were given in anticipation of your next visit.
Orders to be placed?:
Yes
Yes (**Please send a copy of the orders to the patients case manager**)
No
New Orders/Referrals:
Medication: We will be putting in a new prescription for medication.
Radiology
Pain Management
PT: West Ashley, Johns Island, James Island
PT: Mt. Pleasant, Daniel Island
PT: N. Charleston, Nexton, Summerville, Carnes Crossroads, Goose Creek, Moncks Corner, Hanahan
PT: Downtown Charleston
PT: Walterboro, Colleton
PT: Beaufort
PT: Hilton Head, Bluffton, Okatie
PT: Hampton, Varneville
PT: Eutawville, Santee
PT: Orangeburg
Neurology
EMG/NCS
FCE (Functional Capacity Examination)
Psychology
Hand Surgeon
Vascular Surgeon
Neurosurgeon
General Orthopedics (Shoulder, Hip, Knee, Etc)
Handicap Placard
NONE - There are NO new orders or tests that were ordered during todays visit.
Handicap placard for six months.
Handicap placard for one year.
Other
PHYSICAL THERAPY
You are being sent to Physical Therapy for:
Neck Pain
Upper extremity radiculopathy
Thoracic pain
Low back pain
Lower extremity radiculopathy
Post-op pain
Other
Home Health Agencies:
Amedysis Home Health
Physical Therapy: North Charleston
North Charleston: Atlas PT (843-225-6985)
North Charleston: Axis PT (843-300-8585)
North Charleston: Cora PT (843-507-8469)
North Charleston: Imagine PT (843-375-5448)
North Charleston: Premier PT (843-797-5197)
North Charleston: Select PT (843-767-3765)
North Charleston: Results PT (843-695-7970)
North Charleston: Roper/ATI (843-773-2841)
North Charleston: Carolina PT (843-277-0710)
Palmetto Advanced Therapy & Rehab (843-203-5051)
Physical Therapy: Orangeburg
Orangeburg: MUSC HealthPlex (803-395-2804)
Physical Therapy: Summerville, Carnes Crossroads, Nexton
Summerville: Atlas PT (843.261.1000)
Summerville: Flowertown PT (843-970-7000)
Summerville: Grace PT (843-871-3522)
Summerville: Select PT (843-821-2272)
Summerville: Results PT (843-695-7970)
Summerville: Roper/ATI (843-773-2841)
Summerville: Axis PT (843-419-6393)
Carnes Crossroads: Cora PT (843-507-8190)
Carnes Crossroads: Axis PT (843-284-9300)
Physical Therapy: Eutawville, Santee
MUSC HealthPlex (803-395-2090)
Physical Therapy: Goose Creek
Goose Creek: Results PT (843-695-7970)
Goose Creek: Select PT (843-569-2303)
Goose Creek: Roper/ATI (843-773-2841)
Physical Therapy: Moncks Corner
Moncks Corner: Select PT (843-761-6732)
Moncks Corner: Roper/ATI (843-773-2841)
Moncks Corner: Benchmark PT (843-823-4150)
Moncks Corner: Axis PT (843-989-0199)
Physical Therapy: Downtown Charleston
Downtown Charleston: Benchmark PT (843-203-6562)
Physical Therapy: Mt Pleasant
Mt Pleasant: Roper/ATI (843-773-2841)
Mt Pleasant: Results PT (843-695-7970)
Mt Pleasant: Advantage PT (843-718-2683)
Mt Pleasant: Carolina PT (843-388-7667)
Physical Therapy: Daniel Island
Daniel Island: Roper/ATI (843-773-2841)
Daniel Island: Made 2 Move (843-640-5244)
Physical Therapy: West Ashley
West Ashley: Cora PT (854-202-8371)
West Ashley: Results PT (843-695-7970)
West Ashley: Roper/ATI (843-773-2841)
West Ashley: Benchmark PT (843-793-1596)
Physical Therapy: Johns Island
Johns Island: Cora PT (854-800-9890)
Johns Island: Roper/ATI (843-773-2841)
Johns Island: Benchmark PT (843-718-0221)
Physical Therapy: James Island
James Island: Results PT (843-695-7970)
Physical Therapy: Hanahan
Benchmark PT (843-718-1058)
Physical Therapy: Walterboro/Colleton
Walterboro/Colleton: Low Country Rehab (843-538-2055)
Walterboro/Colleton: Colleton Medical Center (843-782-2540)
On-Point PT (formerly Mobile PT) (803-632-3773)
Physical Therapy: Hilton Head/Bluffton/Okatie
Hilton Head: Horizon Rehabilitation & PT (843-671-7342)
Bluffton: Benchmark PT (843-815-2563)
Bluffton: Cora PT (843-507-8473)
Bluffton & Okatie: Elite PT (843-757-5566)
Bluffton: Cornerstone PT (843-837-1930)
Bluffton: Roper/ATI (854-946-2604)
Physical Therapy: Beaufort
Beaufort: Cora PT (843-986-9670)
Beaufort: Gravity PT (843.524.4778)
Beaufort: Beaufort Memorial Outpt Rehab & PT (843.522.5850)
Physical Therapy: Hampton, Varnville
Hampton: On-Point PT (Formerly Mobile PT) (803-632-3773)
Hampton: Hampton Regional PT (803-943-1264)
PAIN MANAGEMENT
You are being referred to pain management for:
Cervical Epidural Steroid Injections (ESI)
Lumbar Epidural Steroid Injections (ESI)
Cervical RFA (Radio Frequency Ablation aka Rhizotomy)
Lumbar RFA (Radio Frequency Ablation aka Rhizotomy)
Spinal Cord Stimulator Evaluation and Trial
SacroIliac (SI) Joint Injection on LEFT, local anesthetic only!
SacroIliac (SI) Joint Injection on RIGHT, local anesthetic only!
SacroIliac (SI) Joint Injection BILATERALLY, local anesthetic only!
Management of non-surgical pain
Triggerpoint injections
You are being referred to this pain management office:
N. Charleston, Pain Spec of Chas, Dr. Tavel & team (843-818-1181)
N. Charleston, Carolina Pain Physicians, Dr. Owens & team (843-737-0437)
N. Charleston, Trident Pain Center, Dr. Nolan & team (843-797-3636)
N. Charleston, Low Country Orthopedics, Dr. Chris Merrell (843-797-5050)
N. Charleston, LowCountry Orthopedics, Dr. Shailesh Patel (843-797-5050)
W. Ashley, DeNovo Pain Mgmt, Dr. Arcella (843-609-2309)
W. Ashley, Pain Institute of Chas, Dr. Gardner (843-974-3959)
W. Ashley, Trident Pain Center, Dr. Nolan & team (843-797-3636)
W. Ashley, Roper Pain Mgmt, Dr. Randall (843-723-8823)
Bluffton, Hilton Head, Coastal Pain and Spine (Dr. Hill, Dr. Kinch)
Mt. Pleasant, Signe Spine, Dr. Nemeth (843-730-4124)
Mt. Pleasant, Southern Grace, Dr. Richardson (843-999-8300)
Mt. Pleasant, Non-surgical Spine Center, Dr. Rob Alexander (843-856-9669)
Walterboro, Trident Pain Center, Dr. Nolan & team (843-797-3636)
Beaufort, Pain Specialists of Chas, Dr. Tavel & team (843-818-1181)
Myrtle Beach & Pawleys Island, Pain Specialists of Chas, Dr. Tavel & team (843-818-1181)
Columbia, Pain Specialists of Chas, Dr. Tavel & team. (843-818-1181)
Columbia, Trident Pain Center, Dr. Nolan & team (843-797-3636)
IMAGING
You are being sent for the following imaging:
MRI Brain, non-contrast
MRI Brain, w/wo contrast
MRI Cervical Spine, non-contrast
MRI Cervical Spine, w/wo contrast
MRI Thoracic Spine, non-contrast
MRI Thoracic Spine, w/wo contrast
MRI Lumbar Spine, non-contrast
MRI Lumbar Spine, w/wo contrast
CT Brain, non-contrast
CT Brain, w/wo contrast
CT Cervical Spine, non-contrast
CT Cervical Spine, w/wo contrast
CT Thoracic Spine, non-contrast, Globus Protocol (.625mm or less, Axial Cuts)
CT Thoracic Spine, w/wo contrast, Globus Protocol (.625mm or less, Axial Cuts)
CT Lumbar Spine, non-contrast, Globus Protocol (.625mm or less, Axial Cuts)
CT Lumbar Spine, w/wo contrast, Globus Protocol (.625mm or less, Axial Cuts)
CT *MYELOGRAM* Cervical Spine
CT *MYELOGRAM* Thoracic Spine, Globus Protocol (.625mm or less, Axial Cuts)
CT *MYELOGRAM* Lumbar Spine, Globus Protocol (.625mm or less, Axial Cuts)
Xray Cervical Spine, 3-views (includes Odontoid view). *An Xray was ordered. You do not need to wait for the facility to call you. You can show up on any day of the workweek and go to the radiology department. They will have your referral ready and will take your Xrays.
Xray Cervical Spine, AP & Lateral views. [*An Xray was ordered. You do not need to wait for the facility to call you. You can show up on any day of the workweek and go to the radiology department. They will have your referral ready and will take your Xrays.]
Xray Cervical, Flexion & Extension views. [*An Xray was ordered. You do not need to wait for the facility to call you. You can show up on any day of the workweek and go to the radiology department. They will have your referral ready and will take your Xrays.]
Xray Thoracic Spine, AP & Lateral views. [*An Xray was ordered. You do not need to wait for the facility to call you. You can show up on any day of the workweek and go to the radiology department. They will have your referral ready and will take your Xrays.]
Xray Lumbar Spine, AP & Lateral views. [*An Xray was ordered. You do not need to wait for the facility to call you. You can show up on any day of the workweek and go to the radiology department. They will have your referral ready and will take your Xrays.]
Xray Skull for shunt valve setting. [*An Xray was ordered. You do not need to wait for the facility to call you. You can show up on any day of the workweek and go to the radiology department. They will have your referral ready and will take your Xrays.]
Xray Skull for shunt valve setting. Please call us directly at 843.813.6364 or 919.623.1949 BEFORE letting the patient leave. This is so that we can determine if it was a good Xray and also to evaluate the setting.
Xray, Shunt series (Must include AP & Lateral Skull, Shunt valve Xray to evaluate the setting, AP & Lateral Thoracic Xrays, AP & Lateral Lumbar Xrays and a KUB)
Other
Does the patient have a spinal cord stimulator or a pacemaker?
Yes - make sure you get the study at Trident & make sure the patient contacts the implant rep several days before the procedure.
No - the MRI can be scheduled anywhere.
Imaging Additional Requests:
STAT: Please order the imaging as STAT (write that on the order)
VALIUM: We will provide the patient with Valium to be taken PRN prior to the study.
CONSCIOUS IV SEDATION: Please order the MRI with conscious IV sedation (*not available for CT Myelograms*)
GENERAL ANESTHESIA: Please order the MRI with General Anesthesia (*not available for CT Myelograms*)
3TESLA: Please add "3 Tesla" to the MRI Order
DELAY: Please order the imaging study to be done one week prior to their next appointment.
Please obtain your imaging at this facility:
American Health Imaging, Mt Pleasant (843-999-0097)
American Health Imaging, Summerville (843.999.0558)
Axis 3T, N. Charleston, (843.300.8585) [*1]
Beaufort Memorial Hospital (BMH), (843.522.5015)
*Bluffton, 3T MRI at Belfair (843.815.9700) *Get your images put on a CD BEFORE you leave the facility*
Colleton, Colleton Medical Center (CMC) (843-867-7387)
Florence MRI and Imaging
Imaging Specialists, Mt Pleasant (843-881-4020) [*1]
MRI of Charleston (Pain Spec/Tavel), N. Charleston (843.737.8137)
MUSC, Downtown Charleston, (843.792.9729)
*Myrtle Beach/Murrells Inlet, Tidelands Health Imaging (843-652-8000) *Get your images put on a CD BEFORE you leave the facility*
PPCP - Palmetto Primary Care Diagnostics (MRI, CT, US), N. Chas. (843.376.4846)
PPCP - Palmetto Primary Care Diagnostics (XRAY), N. Charleston.(843.735.5355) Please call to schedule an appointment for your Xray - Open on weekends!
Roper, Mt Pleasant (843-402-5000)
Roper, Berkeley (843-402-5000)
Roper, W. Ashley (843-402-5000)
Roper, Downtown Charleston (843-402-5000)
Summerville, Summerville Medical Center (843-867-7387) [*1]
Tricounty Radiology, W. Ashley (843-529-0600)
Tricounty Radiology, N. Charleston (843.529.0600) [*1]
Trident Medical Center, N. Charleston, (843-867-7387) [*1]
[*1] = 3T MRI Available.
Please note the following:
GET THE CD: We will not be able to access your imaging at the imaging center you have chosen. You must get your imaging on a CD BEFORE you leave the facility. DO NOT trust them to mail it to us. You will need to bring it with you at your next appointment or mail it to us yourself. We need to view the ACTUAL IMAGES, not just the radiologists report. The actual images are what is put on the CD.
UPLOAD YOUR CD: If you live far away or you just prefer to get us the images as quickly as possible, please go to this side to upload them [XXXXXXXXX]. We still recommend you bring the actual CD with you to your next appointment.
XRAYS: An Xray was ordered. You do not need to wait for the facility to call you. You can show up on any day of the workweek and go to the radiology department. They will have your referral ready and will take your Xrays.
You are being sent to the following NEUROLOGIST:
Neurology Spec of Chas, N.Chas, Dr. Stickler & Dr. Myers, (843-818-1181)
Charleston Neurology, PPCP, Summerville (Dr. Lucas, Dr. Carlile) (843-569-1856)
MUSC Neurology (843-792-3221)
Carolina Neurological Clinic, N.Chas, Dr. Bahadori (843-723-0202)
Tidewater Neurology, Mt. P, Goose Creek, Dwtn Chas, Dr. Charles Kelly (843.553.0997)
We are ordering a Functional Capacity Exams (FCE) at this facility:
Grace PT
Imagine PT
Axis PT
Roper/ATI
Select PT
We are ordering an EMG/NCS at this facility:
Signe Spine, Mt. Pleasant (Dr. Nemeth) (843-730-4124)
Neurology Spec of Charleston, N Chas (Dr. Stickler) (843-818-1181)
Charleston Neurology, PPCP, Summerville (Dr. Lucas, Dr. Carlile) (843-569-1856)
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EMG/NCS: RIGHT UE
EMG/NCS: LEFT UE
EMG/NCS: BILATERAL UE
EMG/NCS: RIGHT LE
EMG/NCS: LEFT LE
EMG/NCS: BILATERAL LE
We are ordering a psychiatry eval for Spinal Stimulation at:
Advantage Point Behavioral, Online (877-583-5633)
Dr. Sheldon Levin, Mt. Pleasant (410-746-8187)
Dr. Erin Burkhill, N. Chas (Pain Spec of Chas) (843-531-9888)
We are referring you to this hand surgeon:
Dr. Kyle Kokko, Summerville and Mt Pleasant (843-429-4263)
Dr. Chris Brooker (843-975-6683)
Dr. Keith Santiago, Lowcountry Orthopedics (843-797-5050)
Dr. Jon DeVries, South Carolina Sports Medicine (843-572-2663)
We are referring you to this Vascular Surgeon:
Dr. Zachary Arthurs @ Coastal Vein & Vascular (843-577.4551)
We are referring you to this Neurosurgeon:
Dr. Stephen Kalhorn, MUSC Neurosurgery (843-792-1414)
Dr. Alex Vandergrift, MUSC Neurosurgery (843-792-1414)
Dr. Guilherme Porto, MUSC Neurosurgery (843-792-1414)
Dr. Abhay Varma, MUSC Neurosurgery (843-792-1414)
We are referring you to this Orthopedics group:
Lowcountry Orthopedics (843-797-5050)
South Carolina Sports Medicine (843-572-2663)
Please note the following:
CALL FACILITY: We have referred you to obtain additional care and/or test at another facility. If they have not called you in five business days, we ask that you give them a call at the number listed next to the facilities name on this document.
Notes:
Notes from Dr. DAgostino and Amanda Crowley, NP
It was a pleasure meeting you today!
We look forward to helping you get better!
We are glad you are feeling better.
If you need anthing in the future, please let us know.
Happy Holidays and Merry Christmas!
Happy Thanksgiving!
Enjoy your upcoming trip!
Happy 4th of July!
Other
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