Doctor information:
Doctor's name:
Patient's name:
Doctor's email address:
Doctor's phone number:
Patient's mailing address and phone numbers:
Doctor's Orders for Patient:
Doctor Comments/Diagnosis:
Patient Test Needed:	Thallium Stress Test (TL201 isotope) Cardiolite Stress Test (Tc99m isotope) Stress EKG Treadmill Test (no isotope) MUGA Scan Adenosine Stress Test (TL201 isotope) Adenosine Stress Cardiolite Test (Tc99m isotope) Parathyroid "Sestamibi" Thyroid Uptake only Thyroid Scan only Thyroid Uptake and Scan Esophageal Transit GI Blood Loss Gastric Emptying Hemangioma HIDA Scan with ejection fraction LeVeen Shunt Liver spleen Liver SPECT Renal Flow and Function DTPA Renal Flow and Function Mag-3 Lasix Renal Captopril Renal Scan Testicular WBC-Ceretec Tc99m Pulmonary perfusion only Bone Scan 3-Phase Bone Scan Limited Bone Scan Whole Body Bone Scan with SPECT Lymphoscintigraphy (Sentinal Node Imaging)