Nuclear Cardiology Order Form

For your convenience, we offer two easy methods to refer your patient. Click here to download a printable form, which may be completed and faxed back to us, or simply complete and submit the electronic form below and we will contact your office.

Patient Name(Required)

First Last

Patient Phone Number(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

DOB(Required)

Patient Weight(Required)

If your patient is over 350 pounds, please contact UAB Nuclear Medicine at 205 975-8326 for scheduling.

MRN

Physician(Required)

First Last

Date of Service(Required)

Office Contact Person(Required)

First Last

Phone Number(Required)

Please make sure that all order requirements are met before sending order or scheduling patients.

ORDER FORM REQUIREMENTS

Attach your most recent clinic note so that we can best serve your patient
Make certain that TKC Nuclear Cardiology Prep instructions are given to the patient
Schedule the patient via Medicine Scheduling by calling 205.801.5655

Recent clinic notes file upload

Max. file size: 8 MB.

ORDERABLE STUDIES(Required)

Myocardial Perfusion Stress Study - Exercise (Treadmill) (GMI)

Myocardial Perfusion Stress Study - Chemical (Regadenoson or Dobutamine) (LEX)

MUGA Resting Equilibrium Radionuclide Angiogram (MUG)

Cardiac Amyloid Study (Tc-99m PYP Imaging) (CAS)

Myocardial Perfusion Resting Study (PRO)

Cardiopulmonary Stress Test - Metabolic Stress Test (MST)-Cardiology

Cardiopulmonary Stress Test – Pulmonary Gas Exchange (PGE) (Fax completed pulmonary lab orders form, last pulmonary clinic note, and most recent spirometry or pulmonary function test to 205-801-8231.)

Myocardial Viability Study (VIA)

GXT without Imaging (GXT)

DIAGNOSIS(Required)

Other

Signaure(Required)