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:

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

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

Is Patient on Blood Thinners? Yes No If so, Name:_________________________ Dosage:____________________________ Imaging Report (if applicable) Yes No H & P (most recent) No Yes Patient Demographics Yes No

DOB:

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SEX:

M

F

Dr. PAIN Consultation Epidural Steroid Injection: Cervical Thoracic Lumbar Caudal Level: (if known) Facet Injection: Cervical 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

Thoracic

VARICOSE VEIN Evaluate and Treat for Varicose Veins

VENOUS IVC Filter Placement IVC Filter Removal Port Placement Port Removal Tunneled Catheter for Long Term Access Placement Removal Dialysis Catheter: 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 8-17 Turn left onto Gooding Blvd.(North Orange Develo Right on Stagers Loop