Internal Submission
RecordID
Refer a Patient
Intellimed Cardiac Diagnostics' Referral Network
Patients Name
*
First Name
Last Name
Patients Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
DOB
*
-
Month
-
Day
Year
Date
Diagnosis
*
Referring Physician Name
*
First Name
Last Name
Referring Physician Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Practice Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Clinicals/Progress Notes
Browse Files
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of
Referring Physician Signature
*
Myocardial Perfusion Imaging
Myocardial Perfusion Imaging
*
Yes
No
SPECT/PET
*
SPECT with Pharm Stress
SPECT with Treadmill Stress
PET with Pharm Stress
N/A
PET with Pharm Stress
Yes
No
SPECT Options
Pharm. Stress
Treadmill Stress
Cardiac Studies
Radionuclide Ventriculography (MUGA)
*
MUGA Rest Only
N/A
Radionuclide Ventriculography Options
Rest Only
Dobutamine
Stress Echocardiogram
*
Yes
No
Stress Echocardiogram Options
Exercise
Dobutamine
Additional Cardiac Studies
Select any additional Cardiac Studies
*
Cardiac Consultation
Echocardiogram/Color Doppler
Stress Echocardiogram - Exercise
Bubble Echo
Treadmill Stress Test
12 Lead EKG
N/A
Peripheral Vascular Studies
Arterial
*
Upper Extremity
Lower Extremity
ABI
Abdominal Aorta
Renal Arteries
Carotid & Vertebral
N/A
Venous
*
Upper Extremity
Lower Extremity
N/A
Submit
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