Patient Referral Form

Seattle Ultrasound AssociatesElmer J. Nordstrom Medical Tower1229 Madison Street, Suite 1150, Seattle, WA 98104Direct Scheduling Line: (206) 386-6399Eleanor Y.L. Djang, MD · Anne E. Freitas, MD · Marianne C. Greenbaum, MDJack H. Hirsch, MD · Barry S. Mahony, MD · Linda M. Pastor, MD · James V. Rogers III, MD · Keith Y. Wang, MDPATIENT NAME: ___________________________________________ REFERRING PROVIDER: ___________________________________PATIENT SS#: ______________________________________________APPOINTMENT DATE: _____________________________________ APPOINTMENT TIME:_____________________________________CLINICAL INFORMATION: _____________________________________________________________________________________________SERUM SCREENING RESULT (IF AVAILABLE):___________________________________________________________________________ULTRASOUND EXAM REQUESTED:___________ FIRST TRIMESTER OBSTETRIC ULTRASOUND___________ INCLUDE NUCHAL TRANSLUCENCY (10.5 - 13 WKS)___________ SECOND TRIMESTER OBSTETRIC ULTRASOUND AND FETAL SCREEN___________ THIRD TRIMESTER OBSTETRIC ULTRASOUND___________ OTHER OB EXAM – PLEASE SPECIFY:__________________________________________________________________________________ PELVIC ULTRASOUNDPREP: DRINK 24 oz. OF FLUID 1 HOUR PRIOR TO EXAM. KEEP BLADDER FULL.___________ OTHER ULTRASOUND – PLEASE SPECIFY: __________________________________________________________________If cancellation is necessary, please call (206) 386-6399 at least 24 hours prior to your scheduled appointment.REPORT REQUEST:___________ WRITTEN REPORT___________ FAX REPORT ASAP TO: ( ) ________________________________________________ M.D. TO CALL REPORT STAT TO: ______________________________________AT (DIRECT LINE): ( ) _________________________________________INSURANCE:□ Aetna US Healthcare□ Basic Health Plan□ Cigna□ DSHS/Welfare Dept Coupon□ First Choice□ First Health Network□ Health Plus□ Labor & Industries/Self-Insured Industrial Claim□ Lifewise□ Medicare□ Multiplan Inc.□ Northstar Administrators□ One Health Plan□ Pacificare of WA□ Pac Med□ Premera Blue Cross□ PHCS□ Regence Blue Shield□ Regence Care□ Retail Clerk□ TriCare□ Uniform Medical Plan□ United Health Care□ Virginia Mason Health Plan□ Not Covered by Insurance□ Other: ___________________Auth: ______________________So that we may devote our full attention and expertise to you, if your bring children,please make arrangements to have them attended. Thank you.

Seattle Ultrasound AssociatesRITE-AID1401MADISONEMERGENCYMAINENTRANCEUNDERGROUND PARKING1229 Madison Street, Suite 1150Nordstrom Medical TowerSeattle, WA 98104(206) 386-6300(206) 386-6399 Scheduling LineFrom I-5 Heading North• Take exit 164A (Dearborn St./James St.) towardMadison Street. Initially stay in the left lane on theexit and then follow signs toward MadisonSt./Convention Place.• Turn right onto Madison Street (first signal).• Go up the hill on Madison Street 1 1 ⁄2 blocks pastBoren Avenue.• Turn right into the circle drive for the NordstromMedical Building parking garage.• Take the main lobby elevator to the 11th floor ofthe Nordstrom Medical Building.From I-5 Heading South• Take exit 165A (Columbia St.).• Turn left at James Street. Go four blocks up the hillto Boren Avenue.• Turn left onto Boren Avenue and go four blocks toMadison Street.• Turn right onto Madison Street.• Go 1 1 ⁄2 blocks then turn right into the circle drivefor the Nordstrom Medical Building parking garage.• Take the main lobby elevator to the 11th floor ofthe Nordstrom Medical Building.Metro Bus Service: City buses travel to our office from Madison Street (#12),Seneca Street (#2) and Jefferson Street (#3 & #4). For further informationconcerning the buses, please call (206) 553-3000. We do not validate parking.