Physician Referral - Fax Cover Sheet

Heart and Vascular Recovery Checklist
And Fax Cover Sheet
For Procedures Scheduled in Cath Lab
And Invasive Radiology

FAX: 706.774.8910
Phone: 706.774.3181

Patient's Name: _________________________________________________________

Physician: ______________________________________________________________

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.