Same Day EKG
In- Facility Order Request
Patient Name
*
First Name
Last Name
Patient DOB
*
-
Month
-
Day
Year
DOB
Where Will the Test be Performed?
*
Facility Name
Address
City
State / Province
Room/Building Number
Referring Doctor
First Name
Last Name
Referring Doctor Phone (for critical results only)
Please enter a valid phone number.
Referring Doctor Email (for all results)
example@example.com
Preferred Report Delivery Method (fax, secure email)
*
Reason for EKG
*
Ordering User's Name
*
First Name
Last Name
Ordering User's Phone
*
Please enter a valid phone number.
Ordering User's Email
*
example@example.com
Preferred Appointment Timeframe
*
Same Day EKG
Next Day EKG
Scheduled Future Date EKG
Special Instructions
Order Authorization & Billing Consent
*
I authorize Same Day EKG powered by Ultra View Imaging to perform an electrocardiogram (EKG), Blood Pressure, and SpO2 on the patient named above at our facility.
I agree that our facility will be invoiced for this service according to our agreed billing terms, and payment will be made upon receipt or by the agreed schedule.
I consent to the secure collection, use, and storage of patient health information for the purpose of performing and interpreting this EKG and providing results to the ordering provider.
Ordering Users Signature
Today's Date
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: