Pioneercardiovascular.com

PIONEER CARIOVASCULAR CONSULTANTS P.C

MEHUL SHAH, M.D. F.A.C.C

PATIENT NAME______________________________________ DATE________________________
YOU HAVE BEEN SCHEDULE FOR THE FOLLOW TEST:
EXERCISE CARDIOLITE TREADMILL OR DOBUTAMINE STRESS TEST

FOR YOUR PROCEDURE:
1. MEDICATIONS: Stop taking beta-blockers 48 Hours prior to the test. If you do not take a beta-
blocker, you may take your other medication as prescribed. See below for a list of beta-blockers 2. FOOD: You may eat a low fat diet up to two hours prior to the test. You may also bring a snack
with you to have during the day, with permission of the nuclear technician: PLEASE EAT BY ____________________am/pm 3. WATER: Increase your water intake 2 days prior to your testing.
4. CLOTHES: Wear confortable TWO PIECE clothing (no dresses) and comfortable running/tennis
5. JEWELRY: DO NOT wear metal necklaces, pins or shirts with metal buttons
6. NON ENGLISH SPEAKING PATIENTS MUST BRING AN INTERPRETER.
7. PLEASE NOTE ********YOU WILL BE HERE FOR 4-5 HOURS***************************
8. IF YOU NEED TO RESCHEDULE OR CANCEL THIS TEST, A 24 HOUR NOTICE IS REQUIRED (If your
test is scheduled for a Monday, please notify us by noon on Friday)
BETA BLOCKS TO BE STOPPED 48 HOURS PRIOR TO TESTING
ATENOLOL
2149 E Baseline Rd Ste 103, Tempe AZ 85283 Phone: 480-345-0034 Please be advised that the dose of medication that we will order for
your nuclear stress test costs our company approximately $150.00.
This dose of medication is a prescription ordered just for you. We
cannot use the medication on another patient. Also, the dose of
medication expires within 6 hours of when it is received in our office.
For this reason we must be notified in a timely manner to cancel your
dose of medication otherwise we will be charged. We must be notified
by 12:00 noon the business day before your appoinment if you are not
going to be able to make it.
IF WE ARE NOT NOTIFIED BY 12:00 NOON THE BUSINESS DAY BEFORE
YOUR TEST OR YOU NO SHOW FOR YOUR TEST YOU WILL BE CHARGED
$150.00.
I______________________________________UNDERSTAND THAT IF I DO NOT SHOW UP FOR MY NUCLEAR STRESS TEST I WILL BE CHARGED $150.00 I ALSO UNDERSTAND THAT IF I DO NOT NOTIFY THE OFFICE BY 12:00 NOON THE BUSINESS DAY BEFORE MY TESTING I WILL BE CHARGED THE NO SHOW FEE OF $150.00, Signature____________________________DATE_______________ PIONEER CARDIOVASCULAR CONSULTANTS P.C. MEHUL SHAH, M.D. F.A.C.C., RAJIV ASHAR, M.D. F.A.C.C. CHRISTOPHER WRIGHT, MD. F.A.C.C. Patient Name:_______________________________________ Date:_____________________ Check in _____________________________________________________________________ FOR YOUR PROCEDURE: CAFFEINE: NO coffee, tea,soda,chocolate, medications containing caffeine, or any
other caffeine products 24 hours prior to the test
FOOD: You may eat a low fat diet up to two hours prior to the test. You may also
bring a snack with you to have during the day, with the permission of the nuclear
technician. Please eat by_______________________________am/pm
WATER: Increase your water intake 2 days prior to your test.
CLOTHES: Wear comfortable TWO PIECE clothing (no dresses)
JEWELRY: Do not wear necklaces, pins or shirts with metal buttons.
NON-ENGLISH SPEAKING PATIENTS MUST BRING AN INTERPRETER
PLEASE NOTE:**********you will be here between 4-5 hours*************** IF YOU NEED TO RESCHEDULE OR CANCEL THIS TEST, A 24 HOUR NOTICE IS REQUIRED. (If your test is schedule for a Monday, Please notify us by noon on Friday) 2149 E Baseline Rd Ste 103 Tempe, AZ 85283

Source: http://www.pioneercardiovascular.com/uploads/PIONEER_CARIOVASCULAR_CONSULTANTS_P_1_.pdf