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Outpatient Order Forms

Welcome to the Memorial Outpatient Services Guide. Physician offices may download and print the patient procedure order forms below. All of the pages are in PDF format; you will need Adobe Acrobat to open them. Click here to download Adobe Acrobat Reader for free.

If you have any questions about the Memorial Outpatient Services Guide, please call Memorial Physician Liaison, Tawnn Hoover at 574-647-7677 or email her at thoover@memorialsb.org.

See the order forms for:

Rehabilitation/Therapy

To schedule an appointment, please call Outpatient Therapy Scheduling at 574-647-2600. Fax orders to 574-239-6460.

Outpatient Therapy Services Order Form

Memorial's Outpatient Therapy Services can serve any of the following needs

  • Physical Therapy
    • Pool Therapy
    • Vestibular/Balance Rehab
  • Speech/Language Pathology
  • Brain Injury Program
  • Neuropsychological Services
  • Driver evaluation
  • Occupational Therapy
  • Hand Therapy (OT/PT)
  • Functional Capacity Evaluation
  • Work Hardening/Conditioning
  • Back School
  • Pelvic Floor/Incontinence Program
  • Augmentative Communication
  • Lymphedema Program

Dietary Consult Services

To schedule appointments, please call 647-7700, or fax order to 647-2200

Dietary Consult Order Form

Radiology Imaging Services

To schedule an appointment, please call Centralized Scheduling at 574-647-7700. Fax orders to 574-647-2200.

Radiology Order Form Exam Preps and Directions to the Facility

Detailed instructions for filling out the order form. Request more Radiology order forms.

Services included in this order form are:

  • CT/CTA
  • GI/GU
  • Mammography
  • Nuclear Medicine
  • Ultrasound
  • X-Ray

Vascular/Interventional Radiology Services

To schedule an appointment, please call Centralized Scheduling at 574-647-7700. Fax orders to 574-647-2200.

Vascular/Interventional Radiology Order Form Exam Preps and Directions to the Facility

Detailed instructions for filling out the order form. Request more Vascular/Interventional Radiology order forms.

Services included in this order form are:

  • Ablation
  • Abscess Drain
  • Alcohol injection of Liver
  • Angioplasty/Stent
  • Aortogram with runoff
  • Arteriogram
  • Arthrogram
  • Aspiration
  • Biliary Catheter
  • Biopsy
  • Bone Marrow Biopsy
  • Chest Tube Placement
  • Chest Tube Pleurodesis
  • Declotting of Fistula
  • Discectomy/Disc Aspiration
  • Discogram
  • Dye Study of Port
  • Embolization
  • Facet Injection
  • Fistulogram
  • Gallbladder Drain
  • IVC Filter/Inferior Vena Cavagram
  • Lumbar Puncture
  • Opening Pressures
  • Methotrexate Injection (Intrathecal)
  • Myelogram
  • Needle Lung Localization
  • Nephrostomy Catheter
  • Neural Foraminal Injection/
    Nerve Root Block
  • Paracentesis
  • Perm Cath/Dialysis Catheter
  • PICC/Peripherally Inserted Catheter
  • Retrieval of Foreign Body
  • Sialogram
  • Transhepatic Cholangiogram
  • Thrombolysis Infusion (TPA)
  • T.I.P.S./Transhepatic Intrahepatic Portosystemic Shunt
  • Thoracentesis
  • Vascular CTA's
  • Vascular Ultrasound
  • Vertebroplasty
  • Venogram
  • Uterine Fibroid Embolization

Cardiology Services

To schedule an appointment, please call Centralized Scheduling at 574-647-7700. Fax orders to 574-647-2200.

Adenosine Sestamibi
Cardiac Catheterization
Dobutamine Echo Stress
Dobutamine Sestamibi
Echocardiogram
Electrophysiology Studies
Nuclear Stress Test
Radio Frequency Ablation

Sestamibi Treadmill
Stress Echocardiogram
Tilt Studies
Transesophageal Echocardiogram
Treadmill Stress Test

Neurodiagnostic Services

To schedule an appointment, please call Centralized Scheduling at 574-647-7700. Fax orders to 574-647-2200.

Evoked Responses

  • Ver. Ser. Baer Combination
  • Visual Evoked Response
  • Somatosensory Evoked Response
  • Somatosensory (SER) For Surgery
  • Brainstem Evoked Response/Tympanogram

EEG - w/prep

  • Electroencephalogram (90 min.)
  • 48 hour Ambulatory- Initial
  • 48 hour Ambulatory 24hr. F/U visit
  • 48 hour Ambulatory 48hr. F/U visit
  • EEG video
  • 24 hour Ambulatory- Initial
  • 24 hour Ambulatory F/U visit

EMG

  • EMG 30 min All Diagnoses
  • EMG 45 min. (Except Bilat Lower Extremity)
  • EMG Bilateral Lower ExtremityNerve Conduction Velocity Study

Outpatient Infusion Services

To schedule an appointment, please call Centralized Scheduling at 574-647-7700. Fax orders to 574-647-2200.

IV FLUIDS

  • IV Fluids (4-8hr.)
  • Solumedrol Injection
  • Epogen/Infed
  • IV Antibiotic
  • IV Antibiotic Elderly
  • IVIG
  • Epogen Injection
  • IM Injection

PICC

  • PICC Insertion
  • PICC Maintenance
  • Synchromed
  • PICC Insertion/Antibiotic

Pulmonary Services

To schedule an appointment, please call Centralized Scheduling at 574-647-7700. Fax orders to 574-647-2200.

Bronchoscopy
Generic Prep Sheet
Hyperbaric Treatments
Methacholine Challenge Study
Pulmonary Function Tests

Respiratory Treatments

Sleep Study

To schedule an appointment, please call Sleep Lab Scheduling at 574-647-1850. Fax orders to 574-647-2363.

Sleep Study
  • Polysomnogram
  • CPAP Titration
  • Multiple Sleep Latency Test