Cardiolite Stress Test

777 Commercial St SE Suite 130

Salem, OR 97301

503-485-4787

CARDIOLITE STRESS TEST

Appointment Date: ______Check-in Time______

Ordering Physician: ______

PROCEDURE:

Your physician has scheduled you for a Nuclear Stress test. This is a oneor two-day procedure where we image your heart under two conditions: in a resting state and after a stress procedure.

INSTRUCTIONS FOR THE TEST:

• No food 4 hours prior to your test. Water only, if needed.
• No caffeinated or decaffeinated products 12 hours prior. (i.e. Coffee, Cocoa, sodas, Tea, chocolate, some headache medications.)
• You should not take any medications containing Theophylline for 24 hours prior to your test. These include Aerolate, Elixophyllin, Quibron-T, Respbid, Slo-bid, Slo-Phyllin, T-Phyl, Theo-24, Theo-Dur, Theochron, Theolair, Uni-Dur, Uniphyl.
• You need to stop your beta blockers (Atenolol, Toprol, Bystolic (nebivolol), Lopressor, Labetalol, Coreg, Carvedilol, Metoprolol) 48 hours prior to your test, unless told to take them by your physician.
• No long acting nitrates for at least 4 hours prior. No nitroglycerine for at least 1 hour prior to test.
• No smoking of any kind for at least 3 hours prior to the test.
• Please bring a list of your medications and a light snack.
• Diabetics- Juice or a light snack as needed 2 hours prior to check-in.
• Wear comfortable clothing and shoes.
• The test will take approximately 3 hours.
• The medication (Sestamibi) used for this test is high in cost ($380) and cannot be used if you are unable to keep your appointment, no-show or do not follow the listed instructions. If you must cancel please give at least 24 hours notice to avoid charges to your account.
• The cost of this test is $2,267.00. Depending on your insurance, your plan requirements, and your deductible, you may have a balance due for this procedure. Please contact your insurance company or our billing office if you have questions.

Due to the limited space available, only medically necessary person(s) will be allowed in our nuclear waiting area. All other person(s) accompanying a patient will be asked to wait in our front waiting area.

I hereby authorize Cascade Cardiology to release to the insurance company(s) any information acquired in the course of my examination or treatment. I agree to be fully responsible for all expenses incurred to my account in the course of my treatment and hereby assign to Cascade Cardiology any and all insurance and settlement benefits due me to the full extent of my financial obligation to Cascade Cardiology. I further understand that my insurance coverage is a relationship between myself and my insurance company and I agree to accept financial responsibility for payment of charges incurred (If patient is minor, parent or guardian sign). For further detail please reference our company Financial Policy. By signing below I acknowledge receipt of a copy of this notice and understand that failure to follow the above listed instructions may result in the test not being performed thus incurring a charge to my account. I hereby consent to medical treatment per the treatment plan established by my doctor.

Print Name: ______Signature: ______Date:______

(Patient Signature or Authorized Representative)

Please follow-up with ______On______@ ______am/pm