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Texas Children s Hospital Medical Center Echocardiogram Request Form West Tower 20th floor To schedule an echocardiogram appointment please complete this form and fax to 832-825-5691 if form is not complete we will not process the appt. Patients under 15kgs and under 3 years of age are sedated a sedation order is required* Please request the second page from our office. DEMOGRAPHIC INFORMATION PLEASE PRINT CLEARLY Patient Name DOB SS Gender Male / Female Race Address City/State/Zip Home/Cell Insurance policyholder DOB SS Relationship Employer Wk Ph Insurance HMO / PPO / POS Benefits Address City/State/Zip Policy ID Group Emergency Contact Tel Relationship PCP Contact/Nurse Tel Fax Sedation Required Yes No Physician Signature Only patients under 3 years old sedation order form required* Please obtain form from our office. DIAGNOSIS CARDIAC REASON FOR ECHO If an insurance authorization is required appt. will not be made Sugarland 281-494-7010 Clear Lake 281-282-1900 Woodlands 936-321-0808 Cy-Fair 281-469-4688 West Campus 832-227-1100. Patients under 15kgs and under 3 years of age are sedated a sedation order is required* Please request the second page from our office. DEMOGRAPHIC INFORMATION PLEASE PRINT CLEARLY Patient Name DOB SS Gender Male / Female Race Address City/State/Zip Home/Cell Insurance policyholder DOB SS Relationship Employer Wk Ph Insurance HMO / PPO / POS Benefits Address City/State/Zip Policy ID Group Emergency Contact Tel Relationship PCP Contact/Nurse Tel Fax Sedation Required Yes No Physician Signature Only patients under 3 years old sedation order form required* Please obtain form from our office. DEMOGRAPHIC INFORMATION PLEASE PRINT CLEARLY Patient Name DOB SS Gender Male / Female Race Address City/State/Zip Home/Cell Insurance policyholder DOB SS Relationship Employer Wk Ph Insurance HMO / PPO / POS Benefits Address City/State/Zip Policy ID Group Emergency Contact Tel Relationship PCP Contact/Nurse Tel Fax Sedation Required Yes No Physician Signature Only patients under 3 years old sedation order form required* Please obtain form from our office. DIAGNOSIS CARDIAC REASON FOR ECHO If an insurance authorization is required appt. will not be made Sugarland 281-494-7010 Clear Lake 281-282-1900 Woodlands 936-321-0808 Cy-Fair 281-469-4688 West Campus 832-227-1100. Patients under 15kgs and under 3 years of age are sedated a sedation order is required* Please request the second page from our office. DEMOGRAPHIC INFORMATION PLEASE PRINT CLEARLY Patient Name DOB SS Gender Male / Female Race Address City/State/Zip Home/Cell Insurance policyholder DOB SS Relationship Employer Wk Ph Insurance HMO / PPO / POS Benefits Address City/State/Zip Policy ID Group Emergency Contact Tel Relationship PCP Contact/Nurse Tel Fax Sedation Required Yes No Physician Signature Only patients under 3 years old sedation order form required* Please obtain form from our office. DIAGNOSIS CARDIAC REASON FOR ECHO If an insurance authorization is required appt. will not be made Sugarland 281-494-7010 Clear Lake 281-282-1900 Woodlands 936-321-0808 Cy-Fair 281-469-4688 West Campus 832-227-1100.

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