{"id":328,"date":"2023-01-17T18:59:41","date_gmt":"2023-01-17T18:59:41","guid":{"rendered":"https:\/\/uabmedicine.org\/blogs\/greyform\/?page_id=328"},"modified":"2023-01-17T18:59:41","modified_gmt":"2023-01-17T18:59:41","slug":"nuclear-cardiology-order-form","status":"publish","type":"page","link":"https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/index.php\/nuclear-cardiology-order-form\/","title":{"rendered":"Nuclear Cardiology Order Form"},"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_69' style='display:none'><div id='gf_69' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_69' id='gform_69'  action='\/blogs\/greyform\/index.php\/wp-json\/wp\/v2\/pages\/328#gf_69' novalidate>\n                        <div class='gform_body gform-body'><div id='gform_fields_69' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_69_1\" class=\"gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\" ><p>For your convenience, we offer two easy methods to refer your patient. <a href=\"https:\/\/www.uabmedicine.org\/wp-content\/uploads\/sites\/3\/2023\/06\/Nuclear-Cardiology-Order-Form-Print-MAY2024-UPDATE.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.<p><\/div><fieldset id=\"field_69_5\" 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_69_5'>\n                            \n                            <span id='input_69_5_3_container' class='name_first' >\n                                                    <input type='text' name='input_5.3' id='input_69_5_3' value='' aria-label='First name'   aria-required='true'     \/>\n                                                    <label for='input_69_5_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_69_5_6_container' class='name_last' >\n                                                    <input type='text' name='input_5.6' id='input_69_5_6' value='' aria-label='Last name'   aria-required='true'     \/>\n                                                    <label for='input_69_5_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_69_4\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_69_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_69_4' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_69_6\" 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_69_6' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1' id='input_69_6_1_container' >\n                                        <input type='text' name='input_6.1' id='input_69_6_1' value=''    aria-required='true'    \/>\n                                        <label for='input_69_6_1' id='input_69_6_1_label' >Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2' id='input_69_6_2_container' >\n                                        <input type='text' name='input_6.2' id='input_69_6_2' value=''     aria-required='false'   \/>\n                                        <label for='input_69_6_2' id='input_69_6_2_label' >Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city' id='input_69_6_3_container' >\n                                    <input type='text' name='input_6.3' id='input_69_6_3' value=''    aria-required='true'    \/>\n                                    <label for='input_69_6_3' id='input_69_6_3_label' >City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state' id='input_69_6_4_container' >\n                                        <select name='input_6.4' id='input_69_6_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_69_6_4' id='input_69_6_4_label' >State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip' id='input_69_6_5_container' >\n                                    <input type='text' name='input_6.5' id='input_69_6_5' value=''    aria-required='true'    \/>\n                                    <label for='input_69_6_5' id='input_69_6_5_label' >ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_6.6' id='input_69_6_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_69_7\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_69_7' >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_7' id='input_69_7' type='text' value='' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_69_7_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_69_7_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_69_7' class='gform_hidden' value='https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_69_14\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_69_14' >Patient Weight<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_14' id='input_69_14' type='number' step='any'   value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_69_14\" \/><\/div><div class='gfield_description' id='gfield_description_69_14'>If your patient is over 350 pounds, please contact UAB Nuclear Medicine at 205 975-8326 for scheduling.<\/div><\/div><div id=\"field_69_8\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_69_8' >MRN<\/label><div class='ginput_container ginput_container_number'><input name='input_8' id='input_69_8' type='number' step='any'   value='' class='medium'      aria-invalid=\"false\"  \/><\/div><\/div><fieldset id=\"field_69_9\" 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_69_9'>\n                            \n                            <span id='input_69_9_3_container' class='name_first' >\n                                                    <input type='text' name='input_9.3' id='input_69_9_3' value='' aria-label='First name'   aria-required='true'     \/>\n                                                    <label for='input_69_9_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_69_9_6_container' class='name_last' >\n                                                    <input type='text' name='input_9.6' id='input_69_9_6' value='' aria-label='Last name'   aria-required='true'     \/>\n                                                    <label for='input_69_9_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_69_10\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_69_10' >Date of Service<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_10' id='input_69_10' type='text' value='' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_69_10_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_69_10_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_69_10' class='gform_hidden' value='https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_69_11\" 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_69_11'>\n                            \n                            <span id='input_69_11_3_container' class='name_first' >\n                                                    <input type='text' name='input_11.3' id='input_69_11_3' value='' aria-label='First name'   aria-required='true'     \/>\n                                                    <label for='input_69_11_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_69_11_6_container' class='name_last' >\n                                                    <input type='text' name='input_11.6' id='input_69_11_6' value='' aria-label='Last name'   aria-required='true'     \/>\n                                                    <label for='input_69_11_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_69_12\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_69_12' >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_12' id='input_69_12' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_69_13\" 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.<\/p>\nORDER FORM REQUIREMENTS\n<ul>\n<li>Attach your most recent clinic note so that we can best serve your patient<\/li>\n<li>Make certain that TKC Nuclear Cardiology 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_69_19\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_69_19' >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_19' id='input_69_19' type='file' class='medium' aria-describedby=\"gfield_upload_rules_69_19\" onchange='javascript:gformValidateFileSize( this, 8388608 );'  \/><span class='gform_fileupload_rules' id='gfield_upload_rules_69_19'>Max. file size: 8 MB.<\/span><div class='validation_message validation_message--hidden-on-empty' id='live_validation_message_69_19'><\/div><\/div><\/div><fieldset id=\"field_69_15\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >ORDERABLE STUDIES<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_69_15'><div class='gchoice gchoice_69_15_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.1' type='checkbox'  value='Myocardial Perfusion Stress Study -  Exercise (Treadmill) (GMI)'  id='choice_69_15_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_69_15_1' id='label_69_15_1'>Myocardial Perfusion Stress Study -  Exercise (Treadmill) (GMI)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_69_15_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.2' type='checkbox'  value='Myocardial Perfusion Stress Study -  Chemical (Regadenoson or Dobutamine) (LEX)'  id='choice_69_15_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_69_15_2' id='label_69_15_2'>Myocardial Perfusion Stress Study -  Chemical (Regadenoson or Dobutamine) (LEX)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_69_15_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.3' type='checkbox'  value='MUGA Resting Equilibrium Radionuclide Angiogram (MUG)'  id='choice_69_15_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_69_15_3' id='label_69_15_3'>MUGA Resting Equilibrium Radionuclide Angiogram (MUG)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_69_15_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.4' type='checkbox'  value='Cardiac Amyloid Study (Tc-99m PYP Imaging) (CAS)'  id='choice_69_15_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_69_15_4' id='label_69_15_4'>Cardiac Amyloid Study (Tc-99m PYP Imaging) (CAS)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_69_15_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.5' type='checkbox'  value='Myocardial Perfusion Resting Study (PRO)'  id='choice_69_15_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_69_15_5' id='label_69_15_5'>Myocardial Perfusion Resting Study (PRO)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_69_15_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.6' type='checkbox'  value='Cardiopulmonary Stress Test - Metabolic Stress Test (MST)-Cardiology'  id='choice_69_15_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_69_15_6' id='label_69_15_6'>Cardiopulmonary Stress Test - Metabolic Stress Test (MST)-Cardiology<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_69_15_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.7' type='checkbox'  value='Cardiopulmonary Stress Test \u2013 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.)'  id='choice_69_15_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_69_15_7' id='label_69_15_7'>Cardiopulmonary Stress Test \u2013 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.)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_69_15_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.8' type='checkbox'  value='Myocardial Viability Study (VIA)'  id='choice_69_15_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_69_15_8' id='label_69_15_8'>Myocardial Viability Study (VIA)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_69_15_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.9' type='checkbox'  value='GXT without Imaging (GXT)'  id='choice_69_15_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_69_15_9' id='label_69_15_9'>GXT without Imaging (GXT)<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_69_16\" 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_69_16'><div class='gchoice gchoice_69_16_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.1' type='checkbox'  value='Abnormal EKG'  id='choice_69_16_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_69_16_1' id='label_69_16_1'>Abnormal EKG<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_69_16_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.2' type='checkbox'  value='Ventricular Tachycardia'  id='choice_69_16_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_69_16_2' id='label_69_16_2'>Ventricular Tachycardia<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_69_16_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.3' type='checkbox'  value='Chest Pain'  id='choice_69_16_3'   \/>\n\t\t\t\t\t\t\t\t<label 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