Referral Checklist
The following checklist describes the information we require when referring a patient. Please be prepared with this information when you contact the Miller Family Heart & Vascular Institute.
Your contact information
- Name
- Address
- Phone Number
- Fax Number
- Email
Information about your patient
- Name
- Birthdate
- Address
- Phone Number
- Social Security Number
- Insurance Information
Your patient's complete Medical History and Records
- Medical History
- Surgeries/Procedures
- Devices: type/settings
Description of your patient's current Medications
- Type(s)
- Dosages
- Allergies
Diagnostic Test reports plus actual films or tracings:
- Cardiac Catheterization: actual film plus report
- Echocardiogram: actual tape plus report
- Thallium Stress Test: actual x-ray film plus report
- Chest x-ray, CT scans, ultrasounds: x-ray films plus report
- Electrocardiograms: actual tracings if available
- Electrophysiology testing: actual tracings and reports
- Other
This information is provided by Cleveland Clinic and is not intended to replace
the medical advice of your doctor or health care provider.
Please consult your health care provider for advice about a specific medical condition.
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