Order Form for Referring Providers — SONOHEALTH

Order Form for Referring Providers

Order Form for Referring Providers

The following form is intended for healthcare professionals only. We will contact patient within 24 hours and schedule when email is received.

Patient Name *

First Name

Last Name

Patient Date of Birth *

Patient Phone

(###)

###

####

Patient Email

Reason for Exam (Dx or ICD-10) *

Patient Insurance (PPO / HMO, Cash) *

Authorization Number (if applicable)

Scheduling Type

Routine Scheduling

STAT

Obstetrics

First Trimester Dating (<11 weeks)

First Trimester, Follow-Up

Nuchal Translucency (11w 1d to 14w 1d)

Nuchal Translucency, Multiples

OB Complete, Anatomical Survey

OB Complete, Anatomical Survey, Multiples

Biophysical Profile

Fetal Growth

AFI

Cervical Length

Placental Location

Cord Doppler

Other

Gynecology

Pelvic Complete

Pelvic Follow-Up

Follicular Study

Breast Unilateral

Breast Bilateral

Abdominal

Abdominal Complete

Abdominal Follow-Up

Abdominal Limited

Gallbladder

Appendix

Thyroid

Testicular / Scrotal

Extremity, non-vascular

Vascular

Carotid

Lower Extremity

Upper Extremity

Referring Provider *

First Name

Last Name

Provider NPI (Required only if ordering exam to Sonohealth for first time)

Referring Provider Phone *

(###)

###

####

Clinic Name

Provider Fax (If preferred method for receiving Report)

(###)

###

####

Referring Provider Email (If preferred method for receiving Report)

Thank you!

Sonohealth Ultrasound, 1915 Adams Avenue, San Diego, CA, 92116, United States619-546-8005

Email us at sonohealthsd.us@gmail.com