Patient Forms

We require the following information before or during your initial office visit:

Information about you
• Name
• Date of birth
• Address
• Phone Number
• Photo identification
• Insurance information – please bring your insurance card with you
• A copy of the order form from your referring physician is required before your study can be performed.

Information about your referring physician
• Name
• Address
• Phone Number
• Fax Number (if applicable)

Your Medical History and Records
Please bring:
• a list of your medications. Also include all vitamins, herbals, or over-the-counter pills or remedies.

• discharge summaries from any recent hospital stays (within the past 3 to 5 years).

• a list of any implanted devices such as pacemakers, implants, or stents.

• If you have had any diagnostic tests or procedures, such as chest x-rays, CT scans, MRIs, or ultrasounds please obtain the images or films.

Other important information to prepare for your visit:

You are encouraged to bring a family member or friend on the day of your appointment, though it is not absolutely necessary, unless your procedure requires a driver to take you home.

 

Forms on this page can be used by patients who would like to have their forms filled out before they arrive for their appointment.

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