Doctor Referral Form

Referring Doctor Information:

Patient Information:

Consultation

Department of Cardiac Imaging:

Nuclear Stress TestChemical Nuclear Stress TestExercise Treadmill TestExercise Stress EchocardiogramChemical Stress EchocardiogramBubble StudyEchocardiogram

Department of Computed Tomography(Tucker):

CTACardiac Calcium ScoringCT ChestCT PelvicCT HeadCT AbdomenCXR

Department of General Ultrasound:

RUQAbdomenThyroidRenalABI/Lower Extremities DuplexCarotidAAA

HPI/HX:

DOEHyperlipidemiaChest DiscomfortAbdominal PainClaudicationABN EKGCPSOB

HTNPADCoughAbdominal BruitAfib/FlutterFamily History of Heart DiseaseAnorexiaLeg Pain

CADCABGDizzinessCarotid BruitLeg EdemaSyncopeAnginaPrecordial Pain

Doctor Name:

Signature:

Atlanta Locations

Sandy Springs Office	Phone: 470-225-6117
Cumming Office	Phone: 678-679-6800
Decatur Office	Phone: 404-856-3550
Johns Creek Office	Phone: 770-622-1622
Tucker Office	Phone: 770-638-1400
Lithonia Office	Phone: 678-578-8900
Lilburn Office	Phone: 770-255-3491
Lawrenceville Office	Phone: 770-513-5999

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