This is NOT an Online-submitable form. You may print this form and hand write
the contents or you may type your responses and then print the completed form.
Please indicate how you would like to be contacted (i.e., fax, phone,
email) and list contact information.
Pertinent History/ Laboratory Abnormalities:
Physical exam findings, i.e., jugular pulses, heart rate,
murmurs (timing and point of maximum intensity), respiratory
abnormalities (i.e., rate, noise, effort-inspiratory, expiratory)
Current Medications and Doses:
Please indicate interpretation/s requested:
Thoracic Radiography ($64)
Echocardiography (digital video files preferred)
ECG, Thoracic Radiography and Echocardiography ($204)
When submitting a FAX or a consultation on a critical case, please
contact the Cardiology Service at 509.335.0711 or
and inform the clinician that the
materials are coming.
Thank you for your referral,