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

    logo

    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: AspirinPlavixCoumadinOther

    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: AspirinPlavixCoumadinOther

      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: AspirinPlavixCoumadinOther

        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 hypertensionManagement of pelvic congestion syndromeManagement of peripheral arterial diseaseManagement of symptomatic uterine fibroidsManagement 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: AspirinPlavixCoumadinOther

          Referring Office’s Information

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

          Bladder ultrasoundBreast ultrasound (please specify type and side)

          Carotid ultrasoundGallbladder ultrasoundMusculoskeletal ultrasound (please specify type and side)

          Obstetric ultrasound (please specify trimester)

          Pelvic ultrasoundProstate ultrasoundRenal ultrasoundScrotal ultrasoundThyroid ultrasoundVenous Doppler ultrasound of the extremities (please specify type and side)

          Other