Physician Referral - Fax Cover Sheet
Heart and Vascular Recovery Checklist
And Fax Cover Sheet
For Procedures Scheduled in Cath Lab
And Invasive Radiology
Patient's Name: _________________________________________________________
Date of Scheduled Procedure: _________________ Time of Arrival to CVR __________
The following information is required to be on record when a patient is scheduled for a procedure in our area (Cardiac Cath, PTCA, Stent, Invasive Radiological Procedures). Please ensure that all necessary information is faxed to the Cardiovascular Recovery Room prior to the patient's scheduled procedure.
[ ] History and Physical dictated within the past 30 days with update note
[ ] Signed Consent form
[ ] Labwork: CBC, BMP, PT within the past 7 days
[ ] EKG with the past 7 days Optional
[ ] Physician Orders
Name of office contact for further information :__________________________
Thank you for choosing Piedmont Augusta.
We hope your experience with us is an excellent one.