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 Regional Health Services.

Please view our Instruction Guide for specific instructions on how to fill out the appropriate order form.

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
• Rehab Tests: (Physical, Speech and Occupational Therapy)

Patient Education Forms

Click on the link below to print the following forms:

CardioVascular Institute (CVI)

• Coronary Angiograms
• Heart Interventions
• Post Vein Ablation Discharge Instructions

Cardiopulmonary

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

Echo Vascular

• Adenosine Cardiolite Stress Test
• Ankle-Brachial Index ABI
• Discharge Instructions After Your Echo Vascular Ultrasound
• Dobutamine Stress Echocardiography - Echo
• Echocardiogram
• Exercise Stress Test
• Nuclear Medicine (Cardiolite) Treadmill Stress Test
• Radiofrequency Ablation Treatment for Varicose Veins - RFA
• Stress Echocardiography - Echo
• Understanding your Echocardiogram
• 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
• Intravenous Pyelogram - IVP
• Lumbar Puncture Discharge Instructions
• Lumbar Puncture
• Magnetic Resonance Imaging - MRI - Without or With Contrast
• Mammography
• Sedation Electroencephalogram
• Ultrasound
• Voiding cystourethrogram - VCUG

Sleep Medicine

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