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Civadallas.com

All appointments: 1.877.CIVA.NOW (1.877.248.2669)
Referring physicians: PLEASE FAX TO 214.361.2153
civadallas.com
Patient . Cardiovascular Diagnosis .
Patient SSN . Patient Ph . Date of Birth .
(Parent or guardian MUST accompany patients under 18 yrs.
Please check which CIVA physician you are referring the patient to: [ ] Jack W. Spitzberg, MD, FACP, FACC, FCCC [ ] Charles B. Levin, MD, FACC [ ] Martin R. Berk, MD, FCCP, FACC, FASE, FAHA [ ] Tony S. Das, MD, FACC [ ] James B. Park, MD, FACC [ ] Kenneth E. Saland, MD, FACC [ ] Brian Lé, MD, FACC [ ] Tulika Jain, MD CARDIOVASCULAR NON-INVASIVE SERVICES TESTING (PLEASE CHECK ALL THAT APPLY)
[ ] Physician Consult
STRESS TESTING
[ ] Physician Consult Endovenous Laser Therapy
NUCLEAR CARDIAC STRESS TESTING
ECHOCARDIOGRAM
MONITORING
PERIPHERAL TESTING
[ ] Lower Extremity Arterial Duplex and Segmental Pressures CT ANGIOGRAM
[ ] Lower Extremity Venous Duplex [ ] CT Angiogram – please circle scan requested: [ ] Upper Extremity Arterial Calcium Score only Coronary Carotid Peripheral Renal [ ] Upper Extremity Venous[ ] Transcranial Doppler with micro bubble injection Please fax patient’s demographic/insurance information, recent creatinine, current resting HR, and med list to 214.369.6042.
Appointment Date . Check-in Time . Appointment Time .
PATIENTS: Please review the back of this form for test instructions and location of our offices. Please bring this form and a picture ID
with you to the test. Please arrive 30 minutes prior to your appointment to complete paperwork. Remember, these tests are scheduled,
so please be on time. (OVER) PG 1 OF 2 REV 9/08
civadallas.com
GENERAL INFORMATION FOR ALL STRESS TESTING AND HOLTER MONITORS
Please wear two-piece, comfortable clothing. You will be asked to remove your shirt/top for the EKG monitoring patches to be applied. A cape will be provided for female patients. Please do NOT use lotion or powder on your chest the day of the test. Men may require shaving of chest hair.
SPECIFIC INSTRUCTIONS FOR NUCLEAR CARDIAC STRESS TESTS
(Our nuclear testing requires patient specific medication. If you fail to keep your appointment, you may be
charged for the cost of the medication.)
• Please DO NOT take the fol owing medications 24 hours before your test UNLESS instructed differently by your physician/provider:
– Beta Blockers (Atenolol, Tenormin, Zebeta, Coreg, Lopressor, Metoprolol, Toprol, Corgard, Inderal, Propanolol, Bystolic or Nadolol)
– These specific Calcium Channel Blockers (Cardizem, Cartia, Diltiazem, Tiazac, Verapamil, Calan, Covera, Verelan, or Isoptin)
• No caffeine or nicotine 24 hours prior to your test. No food or drink (except water) after midnight.
• If you are diabetic, you may have 1 slice of dry toast, 1 egg and an 8 oz. glass of juice at 6 or 7 am.
• You wil have an IV started in your hand/arm prior to the test beginning. This al ows us to give you an imaging medication that highlights your
heart muscle.
• Test time takes approximately 4 hours but you are not exercising or taking pictures the entire time. There is waiting time between
stages of the test so bring a form of entertainment or work with you and a snack that you can eat when you are advised to do so.
APPROXIMATE TEST TIME: 4 HOURS.
SPECIFIC INSTRUCTIONS FOR STRESS TEST/STRESS ECHOCARDIOGRAM TEST
• Please DO NOT take the fol owing medications 24 hours before your test UNLESS instructed differently by your physician/provider:
– Beta Blockers (Atenolol, Coreg, Tenormin, Zebeta, Lopressor, Metoprolol, Toprol, Corgard, Inderal, Propanolol, Bystolic or Nadolol)
– These specific Calcium Channel Blockers (Cardizem, Cartia, Diltiazem, Tiazac, Verapamil, Calan, Covera, Verelan, or Isoptin)
• No caffeine on the day of your stress test. No nicotine for at least 4 hours prior to your stress test
• No food or drink (except water) at least 3 hours prior to your stress test.
• Occasional y in the event that we are not able to obtain a clear picture of your heart, an IV wil be started in your arm so a contrast
medication may be given.
• If you are to have a Dobutamine Stress Test, an IV will be started in your arm in order to give you a medication that will help increase your
heart rate that is needed for the test.
APPROXIMATE TEST TIME: 1 HOUR. DObUTAMINE STRESS TEST 1.5 HOURS.
SPECIFIC INSTRUCTIONS FOR PERIPHERAL TESTING
For a Peripheral Test, you may need to undress from the waist down and a sheet will be draped to cover you.
APPROXIMATE TEST TIME: 30 MINUTES.
SPECIFIC INSTRUCTIONS FOR CT ANGIOGRAM SCANS
An instruction sheet with directions to the Carrell Clinic Building will be sent to you once you have been scheduled for the scan.
APPROXIMATE TEST TIME: 30 MINUTES.
Please visit our website at civadallas.com for maps and driving directions to our locations. On our website
new patients will also find the required paperwork which can be printed out and brought to your appointment.
[ ] DALLAS 7150 Greenvil e Avenue, Suite 500, Dal as, TX 75231-7906. 214.369.3613
[ ] GREENVILLE, TEXAS Presbyterian Professional Bldg., 4211 Joe Ramsey Blvd. E., Suite 101, Greenville, TX 75401 903.408.7920
[ ] ROCKWALL 1005 West Ralph Hall Pkwy., Suite 137, Rockwall, TX 75032 214.369.3613
[ ] DALLAS CARRELL CLINIC (CT SCANS) 9301 N. Central Expressway, Tower 1, Suite 410, Dal as, TX 75231-0805 214.265.6350
CANCELLATION POLICY
Please let us know 24 hours in advance if you need to cancel a test appointment. Call 214.369.3613, which is answered 24 hrs/day.

Source: http://www.civadallas.com/docs/civaform_non-invasivelabref.pdf

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