Nuclear Cardiology Referral 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*
First Last
Patient Phone Number*
Address*
Street Address Address Line 2 City State ZIP Code
DOB*
MM slash DD slash YYYY
Patient Weight*
If your patient is over 350 pounds, please contact UAB Nuclear Medicine at 205 975-8326 for scheduling.
MRN
Physician*
First Last
Date of Service*
MM slash DD slash YYYY
Office Contact Person*
First Last
Phone Number*
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
- Fax or email this order form to Medicine Scheduling (Fax 205.801.8107, Email domoutsiderorders@uabmc.edu)
- Schedule the patient via Medicine Scheduling by calling 205.801.5655
Recent clinic notes file upload
Max. file size: 2 MB.
ORDERABLE STUDIES*
- 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*
- Abnormal EKG
- Ventricular Tachycardia
- Chest Pain
- Shortness of Breath
- Syncope
- Chest Tightness
- Coronary Artery Disease
- Asymptomatic with high CAD risk
- Asymptomatic with high calcium score
- Cardiomyopathy
- CHF
- CHF new onset
- Ischemic Heart Disease
- Myocardial Infarction History
- Post CABG
- Post CABG greater than 5 years
- Post CABG with incomplete revascularization
- Preop Liver/Kidney Transplant
- Preop Surgery
- Abnormal Treadmill Stress Tes
- Other
Other
Signaure*