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The Kroll Medical Group

Check Out Information

Patient Name

Date of Birth

Date

Next Appointment

Blood Work

Radiology Tests

Subspecialist Referral

Special Instructions

Laboratory Testing

CBC w/Diff

CMP

Fasting Lipid Profile

HbA1C

TSH

FT4

PSA

NMR Profile

U/A C+S

U/A

Iron

Sedimentation Rate

CRP

Uric Acid

CPK

Hepatic Profile

Amylase/Lipase

Vit D 25-OH

ICD10

R10.10 Abd Pain

R68.89 Abnormal Findings

R79.89 Abnormal Labs

D67.9 Anemia

M25.50 Arthralgia

I65.29 Carotid Disease

N41.1 BPH

I50.9 CHF

E11.9 Diabetes

R53.81 Fatigue

M10.10 Gout

K59.0 GI Disturbance

R51 Headach

I10 HTN

R79.9 Hyperglycemia

R78.5 Hyperlipidemia

E03.9 Hypothyroidism

R79.899 Long term Med

I88.9Lymphadenopathy

M79.1 Myalgia

M79.2 Neuralgia

I73.9 PVD

R21 Rash

N18.9 Renal Disturbance

R22.9 Swelling/Mass

R55 Syncope

R30.0 Urine Disturbance

E55.9 Vitamin D disorder

R63.4 Weight Loss

Other

Radiology Test(s)

Other ICD10

Subspecialty Referral

Sent to Front Desk

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The Kroll Medical Group