STATUS: URGENT (within 48 business hrs) STANDARD 5795 Arville St. Suite 200 LV, NV. 89118 9414 Del Webb Blvd. Las Vegas, NV. 89134 3150 N. Tenaya Way Suite 320 LV, NV. 89128 4275 S. Burnham Ave. Suite 100 LV NV 89119 500 E. Windmill Lane Suite 140 LV, NV. 89123 38 Water Street Suite 310 Henderson, NV. 89015 Patient Name:_____________________ DOB: ___/___/___ Age: ___ Home Phone: (___)____-__________ Cell Phone: (___)____-_____ SS# _____-___-_____ Insurance:______________ Auth:_________________ Consultation Pre-Op Clearance Surgery Date_________________Type Of Procedure Scheduled_______________________________________ Vein Evaluation Electrocardiogram Echocardiogram, 2 Dimensional and Doppler Analysis Stress Test Routine Treadmill Nuclear Treadmill Nuclear Lexiscan Nuclear Dobutamine PET Ischemia Viability CTA Coronary Arteries Aorta Abdominal Carotid Renal Arteries Aorta Thoracic Chest Lower Extremity Event Recorder Holter monitor 24 Hours 48 Hours Ultrasound Abdominal Aorta Carotid Arteries Extremity, Arterial Extremity, Venous Comments/Requests: _____________________________________________________________________________ ________________________________________________________________________________________________ Office: (702) 227-3422 FAX TO: 702-240-3428 Dr. Chowdhury Ahsan Dr. Arturo Marchand Jr. Dr. Jose Aquino Dr. Cres Miranda Jr. Dr. Robert Berkley Dr. William Resh Dr. John Bowers Dr. C. Allen Rhodes Dr. Raj Chanderraj Dr. Stephen Savran Dr. Arjun Gururaj Dr. Deepak Sharma Dr. Richard Shehane Dr. Shahabuddin Khan Dr. Nicholas Tselikis Dr. John Lee Dr. Branavan Umakanthan Dr. Sanjay Malhotra Dr. Rafael Valencia Dr. Sunil Kalla Dr. Robert Wesley STAT ________________________________________________________________________________________________ 2779 W. Horizon Ridge Pwky Suite 240 Henderson, NV. 89052 Referring Physician:__________________________________________Phone:(_____)______-___________ Requested Cardiologist:___________________________________________________________________ Clinical Indication:_________________________________________________________________________
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STATUS: URGENT (within 48 business hrs) STANDARD
5795 Arville St. Suite 200 LV, NV. 891189414 Del Webb Blvd. Las Vegas, NV. 891343150 N. Tenaya Way Suite 320 LV, NV. 891284275 S. Burnham Ave. Suite 100 LV NV 89119500 E. Windmill Lane Suite 140 LV, NV. 8912338 Water Street Suite 310 Henderson, NV. 89015
Patient Name:_____________________ DOB: ___/___/___ Age: ___ Home Phone: (___)____-__________
Cell Phone: (___)____-_____ SS# _____-___-_____ Insurance:______________ Auth:_________________
Consultation
Pre-Op Clearance
Surgery Date_________________Type Of Procedure Scheduled_______________________________________
Vein Evaluation
Electrocardiogram
Echocardiogram, 2 Dimensional and Doppler Analysis
Stress Test Routine Treadmill Nuclear Treadmill Nuclear Lexiscan Nuclear Dobutamine
PET Ischemia Viability
CTA Coronary Arteries Aorta Abdominal Carotid Renal Arteries Aorta Thoracic Chest Lower Extremity
Event Recorder
Holter monitor 24 Hours 48 Hours
Ultrasound Abdominal Aorta Carotid Arteries Extremity, Arterial Extremity, Venous
Comments/Requests: _____________________________________________________________________________
________________________________________________________________________________________________
Office: (702) 227-3422
FAX TO: 702-240-3428
Dr. Chowdhury Ahsan Dr. Arturo Marchand Jr. Dr. Jose Aquino Dr. Cres Miranda Jr.Dr. Robert Berkley Dr. William Resh Dr. John Bowers Dr. C. Allen RhodesDr. Raj Chanderraj Dr. Stephen SavranDr. Arjun Gururaj Dr. Deepak Sharma
Dr. Richard ShehaneDr. Shahabuddin Khan Dr. Nicholas TselikisDr. John Lee Dr. Branavan UmakanthanDr. Sanjay Malhotra Dr. Rafael Valencia
Dr. Sunil Kalla
Dr. Robert Wesley
STAT
________________________________________________________________________________________________
2779 W. Horizon Ridge Pwky Suite 240 Henderson, NV. 89052
Referring Physician:__________________________________________Phone:(_____)______-___________
Requested Cardiologist:___________________________________________________________________
Clinical Indication:_________________________________________________________________________
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