{"id":3243,"date":"2017-02-28T08:36:56","date_gmt":"2017-02-28T14:36:56","guid":{"rendered":"http:\/\/www.medradclinics.com\/?page_id=3243"},"modified":"2017-04-06T13:38:27","modified_gmt":"2017-04-06T18:38:27","slug":"form_v2","status":"publish","type":"page","link":"https:\/\/www.medradclinics.com\/?page_id=3243","title":{"rendered":"Order form"},"content":{"rendered":"<div class=\"select\">\n<span>Select a form to order ultrasound exam \/ intervention<\/span><br \/>\n<select><option value=\"\">&#8212;<\/option><option value=\"ff1\">Catheter Interventions<\/option><option value=\"ff2\">Interventions on HD Accesses<\/option><option value=\"ff3\">Minimally-Invasive Interventions<\/option><option value=\"ff4\">Ultrasound Examinations<\/option><\/select>\n<\/div>\n<div class=forms_bl>\n<div class=\"formtos ff1\">\n<div class=\"print\" onClick=\"window.print()\">\n<\/div>\n<div class=\"clearfix\"><\/div>\n\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f3190-o1\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"3190\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F3243#wpcf7-f3190-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"3190\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.4\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f3190-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/fieldset>\n<div class=\"form\">\n\t<div class=\"form_hed\">\n\t\t<div class=\"left\">\n\t\t\t<div>\n\t\t\t\t<p>MEDRAD CLINICS, S.C.<span>(Center for minimally invasive interventions.)<\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div>\n\t\t\t\t<p>KENNETH U. EKECHUKWU, MBBS, MPH, FACP<br \/>\n<!--<a href=\"mailto:kekechukwu@medradclinics.com\">kekechukwu@medradclinics.com<\/a>-->\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"center\">\n\t\t\t<p><img decoding=\"async\" class=\"img-responsive\" src=\"http:\/\/www.medradclinics.com\/wp-content\/uploads\/2016\/08\/mdr_logo.png\" alt=\"logo\" \/>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"right\">\n\t\t\t<div>\n\t\t\t\t<p>1225 HARLEM AVENUE\n\t\t\t\t<\/p>\n\t\t\t\t<p>FOREST PARK, ILLINOIS 60130\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div>\n\t\t\t\t<p>TELEPHONE: <a href=\"tel:(708) 657-4540\">(708) 657-4540<\/a><br \/>\nFACSIMILE: <span>(708) 657-4535<\/span><br \/>\nWEBSITE: <a href=\"www.medradclinics.com\">www.medradclinics.com<\/a>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"clearfix\">\n\t<\/div>\n\t<div class=\"newform\">\n\t\t<h2>Catheter Interventions\n\t\t<\/h2>\n\t\t<table>\n\t\t\t<tr>\n\t\t\t\t<td class=\"title\" colspan=\"6\">\n\t\t\t\t\t<p>Patient\u2019s information\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t<\/tr>\n\t\t\t<tr>\n\t\t\t\t<td colspan=\"6\">\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"reason\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Reason for this order:\" value=\"\" type=\"text\" name=\"reason\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t<\/tr>\n\t\t\t<tr>\n\t\t\t\t<td class=\"half\" colspan=\"2\">\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Name:\" value=\"\" type=\"text\" name=\"name\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"DOB\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"DOB:\" value=\"\" type=\"text\" name=\"DOB\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap date\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required\" type=\"text\" aria-required=\"true\" placeholder=\"Ordering Date:\" value=\"\" name=\"date\" \/> <\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p>Sex: <span class=\"wpcf7-form-control-wrap\" data-name=\"sex\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"sex\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"M\">M<\/option><option value=\"F\">F<\/option><\/select><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"age\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" min=\"1\" max=\"150\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Age\" value=\"\" type=\"number\" name=\"age\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t<\/tr>\n\t\t\t<tr>\n\t\t\t\t<td class=\"half\" colspan=\"3\">\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"address\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Address:\" value=\"\" type=\"text\" name=\"address\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"city\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"City:\" value=\"\" type=\"text\" name=\"city\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"state\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"State:\" value=\"\" type=\"text\" name=\"state\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"zip\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number\" aria-invalid=\"false\" placeholder=\"Zip Code:\" value=\"\" type=\"number\" name=\"zip\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t<\/tr>\n\t\t\t<tr>\n\t\t\t\t<td class=\"half\" colspan=\"3\">\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"homePhone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Home phone:\" value=\"\" type=\"tel\" name=\"homePhone\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td colspan=\"3\">\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"mobilePhone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" placeholder=\"Mobile Phone:\" value=\"\" type=\"tel\" name=\"mobilePhone\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t<\/tr>\n\t\t\t<tr>\n\t\t\t\t<td colspan=\"6\">\n\t\t\t\t\t<p>Check anticoagulation Rx: <span class=\"wpcf7-form-control-wrap\" data-name=\"anticoagulation\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"anticoagulation[]\" value=\"Aspirin\" \/><span class=\"wpcf7-list-item-label\">Aspirin<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"anticoagulation[]\" value=\"Plavix\" \/><span class=\"wpcf7-list-item-label\">Plavix<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"anticoagulation[]\" value=\"Coumadin\" \/><span class=\"wpcf7-list-item-label\">Coumadin<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"anticoagulation[]\" value=\"Other\" \/><span class=\"wpcf7-list-item-label\">Other<\/span><\/span><\/span><\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"anticoagulation_other\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text other\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"anticoagulation_other\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t<\/tr>\n\t\t\t<tr>\n\t\t\t\t<td colspan=\"6\">\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"allergies\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Allergies including iodinated radiocontrast:\" value=\"\" type=\"text\" name=\"allergies\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t<\/tr>\n\t\t\t<tr>\n\t\t\t\t<td class=\"title\" colspan=\"6\">\n\t\t\t\t\t<p>Referring Office\u2019s Information\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t<\/tr>\n\t\t\t<tr>\n\t\t\t\t<td class=\"half\" colspan=\"6\">\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"r_name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Name of Practice:\" value=\"\" type=\"text\" name=\"r_name\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t<\/tr>\n\t\t<\/table>\n\t<\/div>\n\t<div class=\"advance\">\n\t\t<p><br \/>\n<span>Indication:<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Indication\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"Indication\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"Acute renal failure\">Acute renal failure<\/option><option value=\"Chemotherapy\">Chemotherapy<\/option><option value=\"Chronic renal failure\">Chronic renal failure<\/option><option value=\"Parenteral therapy\">Parenteral therapy<\/option><\/select><\/span>\n\t\t<\/p>\n\t\t<p><br \/>\n<span>Type of intervention desired:<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Indication_type\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"Indication_type\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"New central venous catheter insertion\">New central venous catheter insertion<\/option><option value=\"New peritoneal dialysis catheter insertion\">New peritoneal dialysis catheter insertion<\/option><option value=\"Catheter exchange\">Catheter exchange<\/option><option value=\"Catheter removal\">Catheter removal<\/option><option value=\"Other\">Other<\/option><\/select><\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"Indication_type_other\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text other\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Indication_type_other\" \/><\/span>\n\t\t<\/p>\n\t\t<p><br \/>\n<span>Type of Central venous catheter insertion<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"venous_catheter\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"venous_catheter\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"Tunneled\">Tunneled<\/option><option value=\"Non-tunneled\">Non-tunneled<\/option><\/select><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Fax to MRC\" \/>\n\t<\/p>\n<\/div><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n\n<div class=\"print\" onClick=\"window.print()\">\n<\/div>\n<\/div>\n<div class=\"formtos ff2\">\n<div class=\"print\" onClick=\"window.print()\">\n<\/div>\n<div class=\"clearfix\"><\/div>\n\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f3181-o2\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"3181\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F3243#wpcf7-f3181-o2\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"3181\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.4\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f3181-o2\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/fieldset>\n<div class=\"form\">\n\t<div class=\"form_hed\">\n\t\t<div class=\"left\">\n\t\t\t<div>\n\t\t\t\t<p>MEDRAD CLINICS, S.C.<span>(Center for minimally invasive interventions.)<\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div>\n\t\t\t\t<p>KENNETH U. EKECHUKWU, MBBS, MPH, FACP<br \/>\n<!--<a href=\"mailto:kekechukwu@medradclinics.com\">kekechukwu@medradclinics.com<\/a>-->\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"center\">\n\t\t\t<p><img decoding=\"async\" class=\"img-responsive\" src=\"http:\/\/www.medradclinics.com\/wp-content\/uploads\/2016\/08\/mdr_logo.png\" alt=\"logo\" \/>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"right\">\n\t\t\t<div>\n\t\t\t\t<p>1225 HARLEM AVENUE\n\t\t\t\t<\/p>\n\t\t\t\t<p>FOREST PARK, ILLINOIS 60130\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div>\n\t\t\t\t<p>TELEPHONE: <a href=\"tel:(708) 657-4540\">(708) 657-4540<\/a><br \/>\nFACSIMILE: <span>(708) 657-4535<\/span><br \/>\nWEBSITE: <a href=\"www.medradclinics.com\">www.medradclinics.com<\/a>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"clearfix\">\n\t<\/div>\n\t<div class=\"newform\">\n\t\t<h2>Interventions on HD Accesses\n\t\t<\/h2>\n\t\t<table>\n\t\t\t<tr>\n\t\t\t\t<td class=\"title\" colspan=\"6\">\n\t\t\t\t\t<p>Patient\u2019s information\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t<\/tr>\n\t\t\t<tr>\n\t\t\t\t<td colspan=\"6\">\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"reason\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Reason for this order:\" value=\"\" type=\"text\" name=\"reason\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t<\/tr>\n\t\t\t<tr>\n\t\t\t\t<td class=\"half\" colspan=\"2\">\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Name:\" value=\"\" type=\"text\" name=\"name\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"DOB\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"DOB:\" value=\"\" type=\"text\" name=\"DOB\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap date\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required\" type=\"text\" aria-required=\"true\" placeholder=\"Ordering Date:\" value=\"\" name=\"date\" \/> <\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p>Sex: <span class=\"wpcf7-form-control-wrap\" data-name=\"sex\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"sex\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"M\">M<\/option><option value=\"F\">F<\/option><\/select><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"age\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" min=\"1\" max=\"150\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Age\" value=\"\" type=\"number\" name=\"age\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t<\/tr>\n\t\t\t<tr>\n\t\t\t\t<td class=\"half\" colspan=\"3\">\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"address\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Address:\" value=\"\" type=\"text\" name=\"address\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"city\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"City:\" value=\"\" type=\"text\" name=\"city\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"state\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"State:\" value=\"\" type=\"text\" name=\"state\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"zip\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number\" aria-invalid=\"false\" placeholder=\"Zip Code:\" value=\"\" type=\"number\" name=\"zip\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t<\/tr>\n\t\t\t<tr>\n\t\t\t\t<td class=\"half\" colspan=\"3\">\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"homePhone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Home phone:\" value=\"\" type=\"tel\" name=\"homePhone\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td colspan=\"3\">\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"mobilePhone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" placeholder=\"Mobile Phone:\" value=\"\" type=\"tel\" name=\"mobilePhone\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t<\/tr>\n\t\t\t<tr>\n\t\t\t\t<td colspan=\"6\">\n\t\t\t\t\t<p>Check anticoagulation Rx: <span class=\"wpcf7-form-control-wrap\" data-name=\"anticoagulation\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"anticoagulation[]\" value=\"Aspirin\" \/><span class=\"wpcf7-list-item-label\">Aspirin<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"anticoagulation[]\" value=\"Plavix\" \/><span class=\"wpcf7-list-item-label\">Plavix<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"anticoagulation[]\" value=\"Coumadin\" \/><span class=\"wpcf7-list-item-label\">Coumadin<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"anticoagulation[]\" value=\"Other\" \/><span class=\"wpcf7-list-item-label\">Other<\/span><\/span><\/span><\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"anticoagulation_other\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text other\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"anticoagulation_other\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t<\/tr>\n\t\t\t<tr>\n\t\t\t\t<td colspan=\"6\">\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"allergies\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Allergies including iodinated radiocontrast:\" value=\"\" type=\"text\" name=\"allergies\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t<\/tr>\n\t\t\t<tr>\n\t\t\t\t<td class=\"title\" colspan=\"6\">\n\t\t\t\t\t<p>Referring Office\u2019s Information\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t<\/tr>\n\t\t\t<tr>\n\t\t\t\t<td class=\"half\" colspan=\"6\">\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"r_name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Name of Practice:\" value=\"\" type=\"text\" name=\"r_name\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t<\/tr>\n\t\t<\/table>\n\t<\/div>\n\t<div class=\"advance\">\n\t\t<p><br \/>\n<span>Indication:<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Indication\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"Indication\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"Access surveillance\">Access surveillance<\/option><option value=\"Aneurysm\">Aneurysm<\/option><option value=\"\u0421lotted access\">\u0421lotted access<\/option><option value=\"Difficult \u0441annulation\">Difficult \u0441annulation<\/option><option value=\"Diminished flow rate\">Diminished flow rate<\/option><option value=\"High flow rate\">High flow rate<\/option><option value=\"High venous pressure\">High venous pressure<\/option><option value=\"Infiltration\">Infiltration<\/option><option value=\"Limb swelling\">Limb swelling<\/option><option value=\"Non-maturing fistula\">Non-maturing fistula<\/option><option value=\"Pain\">Pain<\/option><option value=\"Planning for a surgically- created fistula\">Planning for a surgically- created fistula<\/option><option value=\"Poor labs\">Poor labs<\/option><option value=\"Prolonged bleeding\">Prolonged bleeding<\/option><option value=\"Recirculation\">Recirculation<\/option><option value=\"Steal syndrome\">Steal syndrome<\/option><option value=\"Other\">Other<\/option><\/select><\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"Indication_other\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text other\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Indication_other\" \/><\/span>\n\t\t<\/p>\n\t\t<p><br \/>\n<span>Type of access:<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Indication_type\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"Indication_type\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"AV fistula\">AV fistula<\/option><option value=\"AV graft\">AV graft<\/option><option value=\"Bilateral upper extremity venogram\">Bilateral upper extremity venogram<\/option><\/select><\/span>\n\t\t<\/p>\n\t\t<p><br \/>\n<span>Location of access:<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"location\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"location\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"Left arm\">Left arm<\/option><option value=\"Left forearm\">Left forearm<\/option><option value=\"Left thigh\">Left thigh<\/option><option value=\"Right arm\">Right arm<\/option><option value=\"Right forearm\">Right forearm<\/option><option value=\"Right thigh\">Right thigh<\/option><option value=\"Other\">Other<\/option><\/select><\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"location_other\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text other\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"location_other\" \/><\/span>\n\t\t<\/p>\n\t\t<p><br \/>\n<span>Desired intervention:<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Desired\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"Desired\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"Duplex ultrasonography\">Duplex ultrasonography<\/option><option value=\"Fistulogram\/graftogram\">Fistulogram\/graftogram<\/option><option value=\"Thrombectomy\">Thrombectomy<\/option><option value=\"Venogram\">Venogram<\/option><option value=\"Other\">Other<\/option><\/select><\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"Desired_other\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text other\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Desired_other\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Fax to MRC\" \/>\n\t<\/p>\n<\/div><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n\n<div class=\"print\" onClick=\"window.print()\">\n<\/div>\n<\/div>\n<div class=\"formtos ff3\">\n<div class=\"print\" onClick=\"window.print()\">\n<\/div>\n<div class=\"clearfix\"><\/div>\n\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f3141-o3\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"3141\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F3243#wpcf7-f3141-o3\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"3141\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.4\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f3141-o3\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/fieldset>\n<div class=\"form\">\n\t<div class=\"form_hed\">\n\t\t<div class=\"left\">\n\t\t\t<div>\n\t\t\t\t<p>MEDRAD CLINICS, S.C.<span>(Center for minimally invasive interventions.)<\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div>\n\t\t\t\t<p>KENNETH U. EKECHUKWU, MBBS, MPH, FACP<br \/>\n<!--<a href=\"mailto:kekechukwu@medradclinics.com\">kekechukwu@medradclinics.com<\/a>-->\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"center\">\n\t\t\t<p><img decoding=\"async\" class=\"img-responsive\" src=\"http:\/\/www.medradclinics.com\/wp-content\/uploads\/2016\/08\/mdr_logo.png\" alt=\"logo\" \/>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"right\">\n\t\t\t<div>\n\t\t\t\t<p>1225 HARLEM AVENUE\n\t\t\t\t<\/p>\n\t\t\t\t<p>FOREST PARK, ILLINOIS 60130\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div>\n\t\t\t\t<p>TELEPHONE: <a href=\"tel:(708) 657-4540\">(708) 657-4540<\/a><br \/>\nFACSIMILE: <span>(708) 657-4535<\/span><br \/>\nWEBSITE: <a href=\"www.medradclinics.com\">www.medradclinics.com<\/a>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"clearfix\">\n\t<\/div>\n\t<div class=\"newform\">\n\t\t<h2>Minimally-Invasive Interventions\n\t\t<\/h2>\n\t\t<table>\n\t\t\t<tr>\n\t\t\t\t<td class=\"title\" colspan=\"6\">\n\t\t\t\t\t<p>Patient\u2019s information\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t<\/tr>\n\t\t\t<tr>\n\t\t\t\t<td colspan=\"6\">\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"reason\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Reason for this order:\" value=\"\" type=\"text\" name=\"reason\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t<\/tr>\n\t\t\t<tr>\n\t\t\t\t<td class=\"half\" colspan=\"2\">\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Name:\" value=\"\" type=\"text\" name=\"name\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"DOB\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"DOB:\" value=\"\" type=\"text\" name=\"DOB\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap date\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required\" type=\"text\" aria-required=\"true\" placeholder=\"Ordering Date:\" value=\"\" name=\"date\" \/> <\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p>Sex: <span class=\"wpcf7-form-control-wrap\" data-name=\"sex\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"sex\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"M\">M<\/option><option value=\"F\">F<\/option><\/select><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"age\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" min=\"1\" max=\"150\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Age\" value=\"\" type=\"number\" name=\"age\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t<\/tr>\n\t\t\t<tr>\n\t\t\t\t<td class=\"half\" colspan=\"3\">\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"address\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Address:\" value=\"\" type=\"text\" name=\"address\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"city\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"City:\" value=\"\" type=\"text\" name=\"city\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"state\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"State:\" value=\"\" type=\"text\" name=\"state\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"zip\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number\" aria-invalid=\"false\" placeholder=\"Zip Code:\" value=\"\" type=\"number\" name=\"zip\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t<\/tr>\n\t\t\t<tr>\n\t\t\t\t<td class=\"half\" colspan=\"3\">\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"homePhone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Home phone:\" value=\"\" type=\"tel\" name=\"homePhone\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td colspan=\"3\">\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"mobilePhone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" placeholder=\"Mobile Phone:\" value=\"\" type=\"tel\" name=\"mobilePhone\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t<\/tr>\n\t\t\t<tr>\n\t\t\t\t<td colspan=\"6\">\n\t\t\t\t\t<p>Check anticoagulation Rx: <span class=\"wpcf7-form-control-wrap\" data-name=\"anticoagulation\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"anticoagulation[]\" value=\"Aspirin\" \/><span class=\"wpcf7-list-item-label\">Aspirin<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"anticoagulation[]\" value=\"Plavix\" \/><span class=\"wpcf7-list-item-label\">Plavix<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"anticoagulation[]\" value=\"Coumadin\" \/><span class=\"wpcf7-list-item-label\">Coumadin<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"anticoagulation[]\" value=\"Other\" \/><span class=\"wpcf7-list-item-label\">Other<\/span><\/span><\/span><\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"anticoagulation_other\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text other\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"anticoagulation_other\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t<\/tr>\n\t\t\t<tr>\n\t\t\t\t<td colspan=\"6\">\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"allergies\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Allergies including iodinated radiocontrast:\" value=\"\" type=\"text\" name=\"allergies\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t<\/tr>\n\t\t\t<tr>\n\t\t\t\t<td class=\"title\" colspan=\"6\">\n\t\t\t\t\t<p>Referring Office\u2019s Information\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t<\/tr>\n\t\t\t<tr>\n\t\t\t\t<td class=\"half\" colspan=\"6\">\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"r_name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Name of Practice:\" value=\"\" type=\"text\" name=\"r_name\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t<\/tr>\n\t\t<\/table>\n\t<\/div>\n\t<div class=\"advance\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"advance\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"advance[]\" value=\"Biopsy (please specify organ)\" \/><span class=\"wpcf7-list-item-label\">Biopsy (please specify organ)<\/span><\/span><\/span><\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"advance_other\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text other\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"advance_other\" \/><\/span>\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"advance2\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"advance2[]\" value=\"Drainage of body fluid by catheter insertion (please specify location and side)\" \/><span class=\"wpcf7-list-item-label\">Drainage of body fluid by catheter insertion (please specify location and side)<\/span><\/span><\/span><\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"advance2_other\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text other\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"advance2_other\" \/><\/span>\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"advance3\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"advance3[]\" value=\"Insertion of a central venous catheter with a subcutaneous port.\" \/><span class=\"wpcf7-list-item-label\">Insertion of a central venous catheter with a subcutaneous port.<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"advance3[]\" value=\"Insertion of a central venous catheter without a subcutaneous port.\" \/><span class=\"wpcf7-list-item-label\">Insertion of a central venous catheter without a subcutaneous port.<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"advance3[]\" value=\"Insertion of peritoneal dialysis catheter.\" \/><span class=\"wpcf7-list-item-label\">Insertion of peritoneal dialysis catheter.<\/span><\/span><\/span><\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"advance4\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"advance4[]\" value=\"Joint aspiration and\/or injection (please specify which joint)\" \/><span class=\"wpcf7-list-item-label\">Joint aspiration and\/or injection (please specify which joint)<\/span><\/span><\/span><\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"advance4_other\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text other\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"advance4_other\" \/><\/span>\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"advance5\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"advance5[]\" value=\"Management of chronic venous hypertension\" \/><span class=\"wpcf7-list-item-label\">Management of chronic venous hypertension<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"advance5[]\" value=\"Management of pelvic congestion syndrome\" \/><span class=\"wpcf7-list-item-label\">Management of pelvic congestion syndrome<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"advance5[]\" value=\"Management of peripheral arterial disease\" \/><span class=\"wpcf7-list-item-label\">Management of peripheral arterial disease<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"advance5[]\" value=\"Management of symptomatic uterine fibroids\" \/><span class=\"wpcf7-list-item-label\">Management of symptomatic uterine fibroids<\/span><\/span><\/span><\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"advance6\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"advance6[]\" value=\"Management of vertebral compression fracture (specify level)\" \/><span class=\"wpcf7-list-item-label\">Management of vertebral compression fracture (specify level)<\/span><\/span><\/span><\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"advance6_other\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text other\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"advance6_other\" \/><\/span>\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"advance7\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"advance7[]\" value=\"Nephrostomy catheter insertion (please specify laterality)\" \/><span class=\"wpcf7-list-item-label\">Nephrostomy catheter insertion (please specify laterality)<\/span><\/span><\/span><\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"advance7_other\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text other\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"advance7_other\" \/><\/span>\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"advance8\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"advance8[]\" value=\"Radiofrequency ablation of a tumor (please specify location and type)\" \/><span class=\"wpcf7-list-item-label\">Radiofrequency ablation of a tumor (please specify location and type)<\/span><\/span><\/span><\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"advance8_other\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text other\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"advance8_other\" \/><\/span>\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"Other_advance\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"Other_advance[]\" value=\"Other\" \/><span class=\"wpcf7-list-item-label\">Other<\/span><\/span><\/span><\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"Other_advance_other\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text other\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Other_advance_other\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Fax to MRC\" \/>\n\t<\/p>\n<\/div><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n\n<div class=\"print\" onClick=\"window.print()\">>\n<\/div>\n<\/div>\n<div class=\"formtos ff4\">\n<div class=\"print\" onClick=\"window.print()\">\n<\/div>\n<div class=\"clearfix\"><\/div>\n\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f3193-o4\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"3193\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F3243#wpcf7-f3193-o4\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"3193\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.4\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f3193-o4\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/fieldset>\n<div class=\"form\">\n\t<div class=\"form_hed\">\n\t\t<div class=\"left\">\n\t\t\t<div>\n\t\t\t\t<p>MEDRAD CLINICS, S.C.<span>(Center for minimally invasive interventions.)<\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div>\n\t\t\t\t<p>KENNETH U. EKECHUKWU, MBBS, MPH, FACP<br \/>\n<!--<a href=\"mailto:kekechukwu@medradclinics.com\">kekechukwu@medradclinics.com<\/a>-->\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"center\">\n\t\t\t<p><img decoding=\"async\" class=\"img-responsive\" src=\"http:\/\/www.medradclinics.com\/wp-content\/uploads\/2016\/08\/mdr_logo.png\" alt=\"logo\" \/>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"right\">\n\t\t\t<div>\n\t\t\t\t<p>1225 HARLEM AVENUE\n\t\t\t\t<\/p>\n\t\t\t\t<p>FOREST PARK, ILLINOIS 60130\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div>\n\t\t\t\t<p>TELEPHONE: <a href=\"tel:(708) 657-4540\">(708) 657-4540<\/a><br \/>\nFACSIMILE: <span>(708) 657-4535<\/span><br \/>\nWEBSITE: <a href=\"www.medradclinics.com\">www.medradclinics.com<\/a>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"clearfix\">\n\t<\/div>\n\t<div class=\"newform\">\n\t\t<h2>Ultrasound Examinations\n\t\t<\/h2>\n\t\t<table>\n\t\t\t<tr>\n\t\t\t\t<td class=\"title\" colspan=\"6\">\n\t\t\t\t\t<p>Patient\u2019s information\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t<\/tr>\n\t\t\t<tr>\n\t\t\t\t<td colspan=\"6\">\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"reason\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Reason for this order:\" value=\"\" type=\"text\" name=\"reason\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t<\/tr>\n\t\t\t<tr>\n\t\t\t\t<td class=\"half\" colspan=\"2\">\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Name:\" value=\"\" type=\"text\" name=\"name\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"DOB\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"DOB:\" value=\"\" type=\"text\" name=\"DOB\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap date\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required\" type=\"text\" aria-required=\"true\" placeholder=\"Ordering Date:\" value=\"\" name=\"date\" \/> <\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p>Sex: <span class=\"wpcf7-form-control-wrap\" data-name=\"sex\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"sex\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"M\">M<\/option><option value=\"F\">F<\/option><\/select><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"age\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" min=\"1\" max=\"150\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Age\" value=\"\" type=\"number\" name=\"age\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t<\/tr>\n\t\t\t<tr>\n\t\t\t\t<td class=\"half\" colspan=\"3\">\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"address\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Address:\" value=\"\" type=\"text\" name=\"address\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"city\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"City:\" value=\"\" type=\"text\" name=\"city\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"state\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"State:\" value=\"\" type=\"text\" name=\"state\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"zip\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number\" aria-invalid=\"false\" placeholder=\"Zip Code:\" value=\"\" type=\"number\" name=\"zip\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t<\/tr>\n\t\t\t<tr>\n\t\t\t\t<td class=\"half\" colspan=\"3\">\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"homePhone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Home phone:\" value=\"\" type=\"tel\" name=\"homePhone\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td colspan=\"3\">\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"mobilePhone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" placeholder=\"Mobile Phone:\" value=\"\" type=\"tel\" name=\"mobilePhone\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t<\/tr>\n\t\t\t<tr>\n\t\t\t\t<td colspan=\"6\">\n\t\t\t\t\t<p>Check anticoagulation Rx: <span class=\"wpcf7-form-control-wrap\" data-name=\"anticoagulation\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"anticoagulation[]\" value=\"Aspirin\" \/><span class=\"wpcf7-list-item-label\">Aspirin<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"anticoagulation[]\" value=\"Plavix\" \/><span class=\"wpcf7-list-item-label\">Plavix<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"anticoagulation[]\" value=\"Coumadin\" \/><span class=\"wpcf7-list-item-label\">Coumadin<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"anticoagulation[]\" value=\"Other\" \/><span class=\"wpcf7-list-item-label\">Other<\/span><\/span><\/span><\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"anticoagulation_other\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text other\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"anticoagulation_other\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t<\/tr>\n\t\t\t<tr>\n\t\t\t\t<td colspan=\"6\">\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"allergies\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Allergies including iodinated radiocontrast:\" value=\"\" type=\"text\" name=\"allergies\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t<\/tr>\n\t\t\t<tr>\n\t\t\t\t<td class=\"title\" colspan=\"6\">\n\t\t\t\t\t<p>Referring Office\u2019s Information\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t<\/tr>\n\t\t\t<tr>\n\t\t\t\t<td class=\"half\" colspan=\"6\">\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"r_name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Name of Practice:\" value=\"\" type=\"text\" name=\"r_name\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t<\/tr>\n\t\t<\/table>\n\t<\/div>\n\t<div class=\"advance\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"advance\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"advance[]\" value=\"Abdominal aortic ultrasound\" \/><span class=\"wpcf7-list-item-label\">Abdominal aortic ultrasound<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"advance[]\" value=\"Abdominal ultrasound\" \/><span class=\"wpcf7-list-item-label\">Abdominal ultrasound<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"advance[]\" value=\"Arterial Doppler ultrasound of the extremities (please specify type and side)\" \/><span class=\"wpcf7-list-item-label\">Arterial Doppler ultrasound of the extremities (please specify type and side)<\/span><\/span><\/span><\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"advance_other\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text other\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"advance_other\" \/><\/span>\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"advance2\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"advance2[]\" value=\"Bladder ultrasound\" \/><span class=\"wpcf7-list-item-label\">Bladder ultrasound<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"advance2[]\" value=\"Breast ultrasound (please specify type and side)\" \/><span class=\"wpcf7-list-item-label\">Breast ultrasound (please specify type and side)<\/span><\/span><\/span><\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"advance2_other\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text other\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"advance2_other\" \/><\/span>\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"advance3\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"advance3[]\" value=\"Carotid ultrasound\" \/><span class=\"wpcf7-list-item-label\">Carotid ultrasound<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"advance3[]\" value=\"Gallbladder ultrasound\" \/><span class=\"wpcf7-list-item-label\">Gallbladder ultrasound<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"advance3[]\" value=\"Musculoskeletal ultrasound (please specify type and side)\" \/><span class=\"wpcf7-list-item-label\">Musculoskeletal ultrasound (please specify type and side)<\/span><\/span><\/span><\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"advance3_other\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text other\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"advance3_other\" \/><\/span>\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"advance4\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"advance4[]\" value=\"Obstetric ultrasound (please specify trimester)\" \/><span class=\"wpcf7-list-item-label\">Obstetric ultrasound (please specify trimester)<\/span><\/span><\/span><\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"advance4_other\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text other\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"advance4_other\" \/><\/span>\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"advance5\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"advance5[]\" value=\"Pelvic ultrasound\" \/><span class=\"wpcf7-list-item-label\">Pelvic ultrasound<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"advance5[]\" value=\"Prostate ultrasound\" \/><span class=\"wpcf7-list-item-label\">Prostate ultrasound<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"advance5[]\" value=\"Renal ultrasound\" \/><span class=\"wpcf7-list-item-label\">Renal ultrasound<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"advance5[]\" value=\"Scrotal ultrasound\" \/><span class=\"wpcf7-list-item-label\">Scrotal ultrasound<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"advance5[]\" value=\"Thyroid ultrasound\" \/><span class=\"wpcf7-list-item-label\">Thyroid ultrasound<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"advance5[]\" value=\"Venous Doppler ultrasound of the extremities (please specify type and side)\" \/><span class=\"wpcf7-list-item-label\">Venous Doppler ultrasound of the extremities (please specify type and side)<\/span><\/span><\/span><\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"advance5_other\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text other\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"advance5_other\" \/><\/span>\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"Other_advance\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"Other_advance[]\" value=\"Other\" \/><span class=\"wpcf7-list-item-label\">Other<\/span><\/span><\/span><\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"Other_advance_other\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text other\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Other_advance_other\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Fax to MRC\" \/>\n\t<\/p>\n<\/div><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n\n<div class=\"print\" onClick=\"window.print()\">\n<\/div>\n<\/div>\n<\/div>\n","protected":false},"excerpt":{"rendered":"<p>Select a form to order ultrasound exam \/ intervention &#8212;Catheter InterventionsInterventions on HD AccessesMinimally-Invasive InterventionsUltrasound Examinations 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