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University Health Network The Dr. Robert J. Burns Nuclear Cardiology Lab PATIENT IDENTIFICATION: M.R.N. # Toronto Western Site NUCLEAR CARDIOLOGY REQUISITION LAB CONTACT INFORMATION: INPT. Opt. Health

How to fill out nuclear cardiology referral form

How to fill out a nuclear cardiology referral form:

1. Start by carefully reading the instructions provided on the form. Make sure you understand all the required information and any specific guidelines mentioned.
2. Begin by filling in the patient's personal information accurately. This includes their full name, date of birth, contact details, and any other necessary demographic information.
3. Provide the details of the referring physician or healthcare provider. Include their name, specialty, contact information, and any relevant identifying numbers such as their medical license number.
4. Fill in the reason for the referral. This could involve indicating the symptoms or medical condition for which the patient requires nuclear cardiology evaluation. Be specific and concise in describing the purpose of the referral.
5. Mention any relevant medical history or previous diagnostic tests performed. Provide necessary details about the patient's past medical conditions, medication history, allergies, and any recent imaging or laboratory results that may be beneficial for the nuclear cardiology evaluation.
6. Include the requested type of nuclear cardiology test or study. Specify the specific procedure or test that the referring physician is requesting for the patient. This may include stress tests, myocardial perfusion imaging, or other cardiac imaging studies.
7. Note any special considerations or specific requirements. If the patient has any specific needs or concerns that should be addressed during the nuclear cardiology procedure, mention them clearly in this section.
8. Ensure that the referring physician has signed and dated the form. Without the physician's signature, the referral may not be considered valid, so double-check this before submitting the form.

Who needs a nuclear cardiology referral form:

1. Patients showing symptoms of cardiovascular or heart-related issues may need a nuclear cardiology referral form. These symptoms may include chest pain, shortness of breath, palpitations, or other indications of cardiac disorders.
2. Individuals with a history of heart disease, heart attacks, or other cardiovascular conditions may require a nuclear cardiology referral form. These referrals aim to assess the current status of the patient's cardiac health and provide necessary diagnostic information for appropriate management.
3. Patients who have undergone previous cardiac procedures or surgeries may need a nuclear cardiology referral form. This allows the healthcare provider to monitor their cardiac function and assess the success of the intervention.
4. Individuals with risk factors for heart disease, such as hypertension, diabetes, or a family history of cardiovascular conditions, might be recommended a nuclear cardiology evaluation. This helps in detecting any underlying cardiac abnormalities early on and managing them effectively.

Remember to consult with a healthcare professional or refer to specific guidelines provided by your institution for accurate and detailed instructions on how to fill out a nuclear cardiology referral form.

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What is nuclear cardiology referral form?

Nuclear cardiology referral form is a document used to refer a patient for nuclear cardiology imaging procedures.

Who is required to file nuclear cardiology referral form?

Cardiologists or referring physicians are required to file the nuclear cardiology referral form.

How to fill out nuclear cardiology referral form?

To fill out the nuclear cardiology referral form, the referring physician must provide patient information, reason for referral, and any relevant medical history.

What is the purpose of nuclear cardiology referral form?

The purpose of the nuclear cardiology referral form is to request and authorize nuclear imaging procedures for the evaluation of cardiac conditions.

What information must be reported on nuclear cardiology referral form?

The nuclear cardiology referral form must include patient demographics, clinical history, referring physician information, and reason for referral.