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REFERRAL FORM

Use this form to send referrals directly to our team.

Portable Service

You must select at least one exam from the list below.

DIGITAL X-RAY
OTHER SERVICES
DIAGNOSTIC CODES
NOTE TO OFFICIALS: A portable service is being ordered since this patient would find it physically and/or psychologically taxing, because of advanced age and/or physical limitations to receive service outside the home. This test is medically necessary for the diagnosis and treatment of this patient. 
ULTRASOUND PREP:
Abdomen - Nothing to eat or drink 4-6 hours prior to the exam.
Bladder - Drink 32oz of water 1 hour prior to the exam.
Renal Arterial Doppler - Nothing to eat or drink 2 hours prior to the exam.

Thanks for your referral!

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