Order form

Select a form to order ultrasound exam / intervention
MEDRAD CLINICS, S.C.(Center for minimally invasive interventions.)
KENNETH U. EKECHUKWU, MBBS, MPH, FACP
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1225 HARLEM AVENUE
FOREST PARK, ILLINOIS 60130
TELEPHONE: (708) 657-4540
FACSIMILE: (708) 657-4535
WEBSITE: www.medradclinics.com

Catheter Interventions

Patient’s information
Sex:
Check anticoagulation Rx:  Aspirin Plavix Coumadin Other
Referring Office’s Information

Indication:

Type of intervention desired:

Type of Central venous catheter insertion

MEDRAD CLINICS, S.C.(Center for minimally invasive interventions.)
KENNETH U. EKECHUKWU, MBBS, MPH, FACP
logo
1225 HARLEM AVENUE
FOREST PARK, ILLINOIS 60130
TELEPHONE: (708) 657-4540
FACSIMILE: (708) 657-4535
WEBSITE: www.medradclinics.com

Interventions on HD Accesses

Patient’s information
Sex:
Check anticoagulation Rx:  Aspirin Plavix Coumadin Other
Referring Office’s Information

Indication:

Type of access:

Location of access:

Desired intervention:

MEDRAD CLINICS, S.C.(Center for minimally invasive interventions.)
KENNETH U. EKECHUKWU, MBBS, MPH, FACP
logo
1225 HARLEM AVENUE
FOREST PARK, ILLINOIS 60130
TELEPHONE: (708) 657-4540
FACSIMILE: (708) 657-4535
WEBSITE: www.medradclinics.com

Minimally-Invasive Interventions

Patient’s information
Sex:
Check anticoagulation Rx:  Aspirin Plavix Coumadin Other
Referring Office’s Information

 Biopsy (please specify organ)

 Drainage of body fluid by catheter insertion (please specify location and side)

 Insertion of a central venous catheter with a subcutaneous port. Insertion of a central venous catheter without a subcutaneous port. Insertion of peritoneal dialysis catheter.  Joint aspiration and/or injection (please specify which joint)

 Management of chronic venous hypertension Management of pelvic congestion syndrome Management of peripheral arterial disease Management of symptomatic uterine fibroids  Management of vertebral compression fracture (specify level)

 Nephrostomy catheter insertion (please specify laterality)

 Radiofrequency ablation of a tumor (please specify location and type)

 Other

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MEDRAD CLINICS, S.C.(Center for minimally invasive interventions.)
KENNETH U. EKECHUKWU, MBBS, MPH, FACP
logo
1225 HARLEM AVENUE
FOREST PARK, ILLINOIS 60130
TELEPHONE: (708) 657-4540
FACSIMILE: (708) 657-4535
WEBSITE: www.medradclinics.com

Ultrasound Examinations

Patient’s information
Sex:
Check anticoagulation Rx:  Aspirin Plavix Coumadin Other
Referring Office’s Information

 Abdominal aortic ultrasound Abdominal ultrasound Arterial Doppler ultrasound of the extremities (please specify type and side)

 Bladder ultrasound Breast ultrasound (please specify type and side)

 Carotid ultrasound Gallbladder ultrasound Musculoskeletal ultrasound (please specify type and side)

 Obstetric ultrasound (please specify trimester)

 Pelvic ultrasound Prostate ultrasound Renal ultrasound Scrotal ultrasound Thyroid ultrasound Venous Doppler ultrasound of the extremities (please specify type and side)

 Other