{"id":316,"date":"2023-01-17T18:50:26","date_gmt":"2023-01-17T18:50:26","guid":{"rendered":"https:\/\/uabmedicine.org\/blogs\/greyform\/?page_id=316"},"modified":"2023-01-17T18:50:26","modified_gmt":"2023-01-17T18:50:26","slug":"ekg-lab-referral","status":"publish","type":"page","link":"https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/index.php\/ekg-lab-referral\/","title":{"rendered":"EKG Lab Referral"},"content":{"rendered":"<script type=\"text\/javascript\">if(!gform){document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0});var gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),null==t&&(t=10),gform.hooks[o][n].push({tag:i,callable:r,priority:t})},doHook:function(o,n,r){if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[o][n]){var t,i=gform.hooks[o][n];i.sort(function(o,n){return o.priority-n.priority});for(var e=0;e<i.length;e++)\"function\"!=typeof(t=i[e].callable)&#038;&#038;(t=window[t]),\"action\"==o?t.apply(null,r):r[0]=t.apply(null,r)}if(\"filter\"==o)return r[0]},removeHook:function(o,n,r,t){if(null!=gform.hooks[o][n])for(var i=gform.hooks[o][n],e=i.length-1;0<=e;e--)null!=t&#038;&#038;t!=i[e].tag||null!=r&#038;&#038;r!=i[e].priority||i.splice(e,1)}}}<\/script>\n                <div class='gf_browser_gecko gform_wrapper gravity-theme' id='gform_wrapper_71' style='display:none'><div id='gf_71' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_71' id='gform_71'  action='\/blogs\/greyform\/index.php\/wp-json\/wp\/v2\/pages\/316#gf_71' novalidate>\n                        <div class='gform_body gform-body'><div id='gform_fields_71' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_71_1\" class=\"gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\" >Thank you for your interest in the UAB Medicine.<\/br>\n<\/br>\nFor your convenience, we offer two easy methods to refer your patient. <a href=\"https:\/\/www.uabmedicine.org\/wp-content\/uploads\/sites\/3\/2023\/03\/EKG-LAB-ORDER-FORM.pdf\" target=\"_blank\">Click here<\/a> 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.<\/div><div id=\"field_71_2\" class=\"gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\" ><style>\nbody {font-family: 'Helvetica', Arial, serif;}\nbody .label .gform_wrapper .gform_body, h1, h2, h2 a, h2 a:visited, h3, h4, h5, h6, p, span, select, textarea {\n    font-family: 'Helvetica', Arial, serif !important;\n}\ninput, label, select, textarea {\nfont-family: 'Helvetica', Arial, serif !important;\n}\n.gform_title { color: #006666 !important; }\nbody .gform_wrapper .gform_footer input[type=submit] {background: #006666;\nborder: 1px solid #006666;\n}\nbody.mocha-gravity-plain {background: transparent !important;\n}\n#content {\n-webkit-box-shadow: 0px 0px 0px 0px !important;\nbox-shadow: 0px 0px 0px 0px !important;\nbackground: #fff !important;\n}\n<\/style><\/div><fieldset id=\"field_71_3\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Patient Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_71_3'>\n                            \n                            <span id='input_71_3_3_container' class='name_first' >\n                                                    <input type='text' name='input_3.3' id='input_71_3_3' value='' aria-label='First name'   aria-required='true'     \/>\n                                                    <label for='input_71_3_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_71_3_6_container' class='name_last' >\n                                                    <input type='text' name='input_3.6' id='input_71_3_6' value='' aria-label='Last name'   aria-required='true'     \/>\n                                                    <label for='input_71_3_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_71_4\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_71_4' >Patient Phone Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_4' id='input_71_4' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_71_5\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address' id='input_71_5' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1' id='input_71_5_1_container' >\n                                        <input type='text' name='input_5.1' id='input_71_5_1' value=''    aria-required='true'    \/>\n                                        <label for='input_71_5_1' id='input_71_5_1_label' >Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2' id='input_71_5_2_container' >\n                                        <input type='text' name='input_5.2' id='input_71_5_2' value=''     aria-required='false'   \/>\n                                        <label for='input_71_5_2' id='input_71_5_2_label' >Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city' id='input_71_5_3_container' >\n                                    <input type='text' name='input_5.3' id='input_71_5_3' value=''    aria-required='true'    \/>\n                                    <label for='input_71_5_3' id='input_71_5_3_label' >City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state' id='input_71_5_4_container' >\n                                        <select name='input_5.4' id='input_71_5_4'     aria-required='true'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_71_5_4' id='input_71_5_4_label' >State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip' id='input_71_5_5_container' >\n                                    <input type='text' name='input_5.5' id='input_71_5_5' value=''    aria-required='true'    \/>\n                                    <label for='input_71_5_5' id='input_71_5_5_label' >ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_5.6' id='input_71_5_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_71_6\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_71_6' >DOB<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_6' id='input_71_6' type='text' value='' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_71_6_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_71_6_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_71_6' class='gform_hidden' value='https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_71_7\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_71_7' >MRN<\/label><div class='ginput_container ginput_container_number'><input name='input_7' id='input_71_7' type='number' step='any'   value='' class='medium'      aria-invalid=\"false\"  \/><\/div><\/div><fieldset id=\"field_71_8\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Physician<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_71_8'>\n                            \n                            <span id='input_71_8_3_container' class='name_first' >\n                                                    <input type='text' name='input_8.3' id='input_71_8_3' value='' aria-label='First name'   aria-required='true'     \/>\n                                                    <label for='input_71_8_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_71_8_6_container' class='name_last' >\n                                                    <input type='text' name='input_8.6' id='input_71_8_6' value='' aria-label='Last name'   aria-required='true'     \/>\n                                                    <label for='input_71_8_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_71_9\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_71_9' >Date of Services<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_9' id='input_71_9' type='text' value='' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_71_9_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_71_9_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_71_9' class='gform_hidden' value='https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_71_10\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Office Contact Person<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_71_10'>\n                            \n                            <span id='input_71_10_3_container' class='name_first' >\n                                                    <input type='text' name='input_10.3' id='input_71_10_3' value='' aria-label='First name'   aria-required='true'     \/>\n                                                    <label for='input_71_10_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_71_10_6_container' class='name_last' >\n                                                    <input type='text' name='input_10.6' id='input_71_10_6' value='' aria-label='Last name'   aria-required='true'     \/>\n                                                    <label for='input_71_10_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_71_11\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_71_11' >Phone Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_11' id='input_71_11' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_71_12\" class=\"gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\" ><p>Please make sure that all order requirements are met before sending order or scheduling patients.<\/br>\n<\/br>\nORDER FORM REQUIREMENTS\n<ul>\n<li>Attach your most recent clinic notes, to help us better serve your patient.<\/li>\n<li>Make certain that TKC EKG prep instructions are given to the patient.<\/li>\n<li>Schedule the patient via Medicine Scheduling by calling 205-801-5655.<\/li>\n<\/ul><\/div><div id=\"field_71_26\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_71_26' >Recent clinic notes file upload<\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='8388608' \/><input name='input_26' id='input_71_26' type='file' class='medium' aria-describedby=\"gfield_upload_rules_71_26\" onchange='javascript:gformValidateFileSize( this, 8388608 );'  \/><span class='gform_fileupload_rules' id='gfield_upload_rules_71_26'>Max. file size: 8 MB.<\/span><div class='validation_message validation_message--hidden-on-empty' id='live_validation_message_71_26'><\/div><\/div><\/div><fieldset id=\"field_71_13\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Test Type<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_71_13'><div class='gchoice gchoice_71_13_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.1' type='checkbox'  value='EKG'  id='choice_71_13_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_71_13_1' id='label_71_13_1'>EKG<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_71_13_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.2' type='checkbox'  value='Research EKG'  id='choice_71_13_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_71_13_2' id='label_71_13_2'>Research EKG<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_71_14\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Monitor<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_71_14'><div class='gchoice gchoice_71_14_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.1' type='checkbox'  value='Holter (not real-time monitoring)'  id='choice_71_14_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_71_14_1' id='label_71_14_1'>Holter (not real-time monitoring)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_71_14_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.2' type='checkbox'  value='30-Day Ambulatory Telemetry Monitor  (MCOT) (real-time monitoring)'  id='choice_71_14_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_71_14_2' id='label_71_14_2'>30-Day Ambulatory Telemetry Monitor  (MCOT) (real-time monitoring)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_71_14_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.3' type='checkbox'  value='Blood Pressure Monitor'  id='choice_71_14_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_71_14_3' id='label_71_14_3'>Blood Pressure Monitor<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_71_25\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_71_25' >Comments<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_25' id='input_71_25' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_71_17\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_71_17' >B\/P<\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_71_17' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_71_15\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Duration<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_71_15'><div class='gchoice gchoice_71_15_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.1' type='checkbox'  value='24-48 hours'  id='choice_71_15_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_71_15_1' id='label_71_15_1'>24-48 hours<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_71_15_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.2' type='checkbox'  value='3-7 days'  id='choice_71_15_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_71_15_2' id='label_71_15_2'>3-7 days<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_71_15_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.3' type='checkbox'  value='Greater than 7 days'  id='choice_71_15_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_71_15_3' id='label_71_15_3'>Greater than 7 days<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_71_18\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Duration<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_71_18'><div class='gchoice gchoice_71_18_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.1' type='checkbox'  value='3-30 days'  id='choice_71_18_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_71_18_1' id='label_71_18_1'>3-30 days<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_71_19\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Duration<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_71_19'><div class='gchoice gchoice_71_19_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.1' type='checkbox'  value='24 hours'  id='choice_71_19_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_71_19_1' id='label_71_19_1'>24 hours<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_71_20\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Diagnosis<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_71_20'><div class='gchoice gchoice_71_20_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.1' type='checkbox'  value='Atrial Fibrillation 427.31'  id='choice_71_20_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_71_20_1' id='label_71_20_1'>Atrial Fibrillation 427.31<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_71_20_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.2' type='checkbox'  value='Acute MI 410.90'  id='choice_71_20_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_71_20_2' id='label_71_20_2'>Acute MI 410.90<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_71_20_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.3' type='checkbox'  value='CV Disease 429.2'  id='choice_71_20_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_71_20_3' id='label_71_20_3'>CV Disease 429.2<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_71_20_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.4' type='checkbox'  value='Chest Pain 428.0'  id='choice_71_20_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_71_20_4' id='label_71_20_4'>Chest Pain 428.0<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_71_20_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.5' type='checkbox'  value='CHF 786.59'  id='choice_71_20_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_71_20_5' id='label_71_20_5'>CHF 786.59<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_71_20_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.6' type='checkbox'  value='Palpitation 785.1'  id='choice_71_20_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_71_20_6' id='label_71_20_6'>Palpitation 785.1<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_71_20_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.7' type='checkbox'  value='Atrial Flutter 427.32'  id='choice_71_20_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_71_20_7' id='label_71_20_7'>Atrial Flutter 427.32<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_71_20_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.8' type='checkbox'  value='Unspecified Conduction Disorder 426.9'  id='choice_71_20_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_71_20_8' id='label_71_20_8'>Unspecified Conduction Disorder 426.9<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_71_20_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.9' type='checkbox'  value='Cardiac Dysrhythmia, Unspecified 427.9'  id='choice_71_20_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_71_20_9' id='label_71_20_9'>Cardiac Dysrhythmia, Unspecified 427.9<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_71_20_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.11' type='checkbox'  value='Heart Transplant V42.1'  id='choice_71_20_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_71_20_11' id='label_71_20_11'>Heart Transplant V42.1<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_71_20_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.12' type='checkbox'  value='Hyperkalemia 276.7'  id='choice_71_20_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_71_20_12' id='label_71_20_12'>Hyperkalemia 276.7<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_71_20_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.13' type='checkbox'  value='Premature Beats 427.60'  id='choice_71_20_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_71_20_13' id='label_71_20_13'>Premature Beats 427.60<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_71_20_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.14' type='checkbox'  value='Hypertension, Benign 401.1'  id='choice_71_20_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_71_20_14' id='label_71_20_14'>Hypertension, Benign 401.1<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_71_20_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.15' type='checkbox'  value='Unstable Angina 411.1'  id='choice_71_20_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_71_20_15' id='label_71_20_15'>Unstable Angina 411.1<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_71_20_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.16' type='checkbox'  value='Other'  id='choice_71_20_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_71_20_16' id='label_71_20_16'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_71_21\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_71_21' >Other<\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_71_21' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_71_22\" class=\"gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\" ><i>NOTICE: For the clinic to bill properly and receive payment for tests you have ordered, it is critical that the diagnosis you provide is consistent with\nthe information recorded in the patient\u2019s medical record. The Department of Health and Human Services requires that all tests ordered for Medicare\nbeneficiaries be reasonable and necessary. If the diagnosis you provide does not support the medical necessity of the test ordered under Medicare\nprogram standards, Medicare will deny payment, and the beneficiary may be financially responsible for the test. <\/i><\/div><fieldset id=\"field_71_23\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Services to be charged to<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_71_23'><div class='gchoice gchoice_71_23_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.1' type='checkbox'  value='Insurance'  id='choice_71_23_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_71_23_1' id='label_71_23_1'>Insurance<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_71_23_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.2' type='checkbox'  value='Clinical Trial'  id='choice_71_23_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_71_23_2' id='label_71_23_2'>Clinical Trial<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_71_23_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.3' type='checkbox'  value='Case'  id='choice_71_23_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_71_23_3' id='label_71_23_3'>Case<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_71_27\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_71_27' >Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_27' id='input_71_27' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><\/div><\/div>\n        <div class='gform_footer top_label'> <input type='submit' id='gform_submit_button_71' class='gform_button button' value='Submit'  onclick='if(window[\"gf_submitting_71\"]){return false;}  if( !jQuery(\"#gform_71\")[0].checkValidity || jQuery(\"#gform_71\")[0].checkValidity()){window[\"gf_submitting_71\"]=true;}  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_71\"]){return false;} if( !jQuery(\"#gform_71\")[0].checkValidity || jQuery(\"#gform_71\")[0].checkValidity()){window[\"gf_submitting_71\"]=true;}  jQuery(\"#gform_71\").trigger(\"submit\",[true]); }' \/> <input type='hidden' name='gform_ajax' value='form_id=71&amp;title=&amp;description=&amp;tabindex=0' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_71' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='71' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_71' value='WyJbXSIsImQ4OGVkZmY0NjE4YzNjYTY4YTYyNWRhMjJjNDUzY2JkIl0=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_target_page_number_71' id='gform_target_page_number_71' value='0' \/>\n            <input type='hidden' class='gform_hidden' name='gform_source_page_number_71' id='gform_source_page_number_71' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <\/form>\n                        <\/div>\n                <iframe style='display:none;width:0px;height:0px;' src='about:blank' name='gform_ajax_frame_71' id='gform_ajax_frame_71' title='This iframe contains the logic required to handle Ajax powered Gravity Forms.'><\/iframe>\n                <script>\ngform.initializeOnLoaded( function() {gformInitSpinner( 71, 'https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/wp-content\/plugins\/gravityforms\/images\/spinner.svg' );jQuery('#gform_ajax_frame_71').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_71');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_71').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! 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