For Referring Physicians

®

Physicians, below you will find a series of documents in PDF form.

Download the form, open the form and print, fill in the necessary information and have your patient bring to their next appointment.

ORDERING SERVICES

Diagnostic Order Form

TO FC

This form is for ordering diagnostic tests that are provided by Foothill Cardiology.

ARCADIA

COVINA

PASADENA

Please select from the list at right to download the form for the correct office location:

MYOCARDIAL PERFUSION PET
PRE-TEST INFO – for Patients

Information for PRE-TEST patients who will be undergoing Myocardial Perfusion PET Imaging.

Click to download the document

FROM FC

DOWNLOAD

OTHER FORMS

Medical Release Form – PATIENT RELEASE

Request for Foothill Cardiology patient medical information to be released to outside sources.

Click to download the document

FROM FC

DOWNLOAD

Medical Release Form –
OUTSIDE REQUEST

Request for patient medical information to be released to Foothill Cardiology.

Click to download the document

TO FC

DOWNLOAD

AUTHORIZATION FOR RELEASE AND / OR DISCLOSURE OF MEDICAL INFORMATION

Completion of these documents authorizes the disclosure and/or use of individually identifiable health information, asset forth below, consistent with the Confidentiality of Medical Information Act of 1981, Civil Code Section 56 et seq,concerning the privacy of such information.

FOR REFERRING
PHYSICIANS