Outpatient Order Forms

We have provided the following outpatient order forms for easy access for physician clinic staff to request a test to be performed at Faith Health.

Available Outpatient Order Forms

Click on the link below and print and complete the order form to schedule the following tests:

• Cardiovascular Pre-Cath
• Outpatient Orders (Cardiopulmonary, Vascular, Radiology and other ancillary tests)
• Lab Tests
• MSP Questionnaire
• PET/CT Scan
• Physician Direct Referral for Home Sleep Apnea Testing
• Physician Direct Referral for In-Lab Sleep Testing
• Outpatient Rehab Consultation Request: (Physical, Speech and Occupational Therapy)

Patient Education Forms

Click on the link below to print the following forms:

CardioVascular Institute (CVI)

• Coronary Angiograms (Spanish)
• Heart Interventions (Spanish)
• Post Vein Ablation Discharge Instructions

Cardiopulmonary

• Bronchoprovocation Methacholine Challenge Test
• Discharge Instructions After Your Stress Test
• Lexiscan Cardiolite Stress Test
• Pulmonary Function Test PFT
• Sleep-Deprived Electroencephalogram - EEG
• Transesophageal Echocardiography - TEE

Echo Vascular

• Ankle-Brachial Index ABI
• Dobutamine Stress Echocardiography - Echo
• Echocardiogram
• Exercise Stress Test
• Nuclear Medicine (Cardiolite) Treadmill Stress Test
• Radiofrequency Ablation Treatment for Varicose Veins - RFA
• Stress Echocardiography - Echo
• Chest Echocardiography (Transthoracic)
• What Is a Duplex Ultrasound

Radiology

• • • Barium Enema for Outpatients
    • Barium Exams Using Fluoroscopy in Radiology
    • Cardiac Blood Pool Image MUGA NMMUGA
    • Computed Tomography (CT)
    • Diagnostic X-Ray Exams
    • Fluoroscopy Injections
    • Lumbar Puncture & Discharge Instructions
    • Magnetic Resonance Imaging - MRI - Without or With Contrast
    • Mammography
    • Ultrasound
    • Voiding Cystourethrogram - VCUG

Sleep Medicine

• • Epworth Sleepiness Scale (Spanish)
  • In-Lab Sleep Testing Instructions
  • Home Sleep Apnea Testing Instructions
  • Stop Bang Questionnaire