Lewis Center Script Form

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PHYSICIAN ORDER FORM Lewis Center Office 7651 Stagers Loop Delaware, OH 43015 Main Number: 740-201-0222 Fax: 740-201-0223

PATIENT NAME: PHONE: REQUESTED PHYSICIAN:

DOB:

Imaging Report (if applicable) Yes No H & P (most recent) No Yes

VARICOSE VEIN Evaluate and Treat for Varicose Veins

Does Patient have Allergies? No Yes If Yes, please list:

Is Patient on Blood Thinners? Yes No If so, Name:_________________________ Dosage:____________________________

Patient Demographics Yes No

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SEX:

M

F

Dr. PAIN Consultation Epidural Steroid Injection: Cervical Thoracic Lumbar Caudal Level: (if known) Facet Injection: Cervical Lumbar Discogram Lumbar Medial Branch Block Radiofrequency Ablation Neuro Stimulator Consultation Trigger Point Injection Selective Nerve Root Block Stellate Ganglion Block Celiac Plexus Block Occipital Nerve Block Joint injection: Knee Shoulder Wrist Ankle Hip Other: Vertebroplasty / Kyphoplasty Thoracic Lumbar

Please fax patient H & P, patient demographics and insurance information along with Order form.

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Thoracic

VENOUS IVC Filter Port Removal Tunneled Catheter for Long Term Access Dialysis Catheter: Placement Removal Groshong Catheter Placement Removal UROLOGY Nephrostogram Nephrostomy Catheter: Removal Exchange Ureteral Stent Removal Exchange GASTROINTESTINAL / BILIARY Biliary Tube Exchange Chole Tube Exchange

directions to Lewis Center O ce

North: 23 South to Gooding Blvd. (light following Home Rd.)

Patient Insurance Info Yes No

Turn right onto Gooding Blvd. And right on Stagers Loop Building is red brick with a green roof

(Located across from the new Orange Township reh

West:

Ordering Physician Signature:

270 North to 23 North/Delaware Exit #23 Travel 23 North past Polaris Pkwy./Powell Rd. Go through Orange Rd. tra c light Next light is Gooding Blvd. on Left Turn left onto Gooding Blvd.(North Orange Develo ____________________________________________________________Date:______________________ Right on Stagers Loop Building is red brick with a green roof

(Located across from the new Orange Township Referring Physician: __________________________________________ Primary Care: ______________________________________

reh

East:

Telephone: ______________________Fax: _______________________ Telephone: _________________ Fax: ____________________ 270 North to 23 North/Delaware Exit #23

Travel 23 North past Polaris Pkwy./Powel Rd. Go through Orange Rd. tra c light Next light is Gooding Blvd. on left Turn left onto Gooding Blvd.(North Orange Develo Right on Stagers Loop