PATIENT INFORMATION:

 LAST NAME:   FIRST NAME:    M.I.  

 DATE OF BIRTH:  SOC SEC #:     GENDER:  MALEFEMALE  

 HOME PHONE:   WORK PHONE:   CELL PHONE:

 ADDRESS: 

 ALLERGIES Please Specify: 

 PATIENT EMAIL (for appointment confirmation): 

 

PROVIDER INFORMATION:

REFERRING PROVIDER (last, first):   

E-MAIL (For Confirmation) 

CC: TO DR. 

RESULTS MANAGEMENT:   - Select One - Phone Prelim Report Fax Final Report Hold Patient and Call Fax Prelim Report Burn to CD Send Films Patient Return with Films - Select One- Phone Prelim Report Fax Final Report Hold Patient and Call Fax Prelim Report Burn to CD Send Films Patient Return with Filmas

PHONE #      FAX # 

CONTACT PERSON (For Questions Regarding Patient): 

 

EXAM INFORMATION:    CONTACT PATIENT TO SCHEDULE

Preferred Date:      Preferred Time:  - Select One - Morning Late Morning Lunchtime Afternoon Evening No Preference

  

Priority:  ASAPROUTINE                       

  

Follow Up Date:     

    PREGNANT       CONTRAST REACTION       HYPERTENSION       PACEMAKER     

    DIABETIC       RENAL FAILURE       CLAUSTROPHOBIC       ALLERGIES     

    Previous surgery on area of interest?      If YES, when   

 

MRI:
EXAM1:   - Select One - CERVICAL SPINE THORACIC SPINE LUMBAR SPINE METASTIC SPINE MR BRAIN MRA, RADS DISCRETION NECK (soft tissue) PITUITARY ORBITS TMJ BONE MARROW CHEST SHOULDER (LEFT) SHOULDER (RIGHT) ARTHROGRAM HIP (LEFT) HIP (RIGHT) KNEE (LEFT) KNEE (RIGHT) EXTREMITY (LEFT) EXTREMITY (RIGHT) LIMITED COMPLETE MR ABDOMEN MRCP KIDNEY LIVER MR PELVIS ORGAN (specify in comments) BONE MR ANGIOGRAM INTRACRANIAL CAROTID AORTA THORACIC RENAL LOWER EXTREMITY RUNOFF OTHER (specify in comments) OTHER (specify in comments)	EXAM2:   - Select One - CERVICAL SPINE THORACIC SPINE LUMBAR SPINE METASTIC SPINE MR BRAIN MRA, RADS DISCRETION NECK (soft tissue) PITUITARY ORBITS TMJ BONE MARROW CHEST SHOULDER (LEFT) SHOULDER (RIGHT) ARTHROGRAM HIP (LEFT) HIP (RIGHT) KNEE (LEFT) KNEE (RIGHT) EXTREMITY (LEFT) EXTREMITY (RIGHT) LIMITED COMPLETE MR ABDOMEN MRCP KIDNEY LIVER MR PELVIS ORGAN (specify in comments) BONE MR ANGIOGRAM INTRACRANIAL CAROTID AORTA THORACIC RENAL LOWER EXTREMITY RUNOFF OTHER (specify in comments) OTHER (specify in comments)	EXAM3:   - Select One - CERVICAL SPINE THORACIC SPINE LUMBAR SPINE METASTIC SPINE MR BRAIN MRA, RADS DISCRETION NECK (soft tissue) PITUITARY ORBITS TMJ BONE MARROW CHEST SHOULDER (LEFT) SHOULDER (RIGHT) ARTHROGRAM HIP (LEFT) HIP (RIGHT) KNEE (LEFT) KNEE (RIGHT) EXTREMITY (LEFT) EXTREMITY (RIGHT) LIMITED COMPLETE MR ABDOMEN MRCP KIDNEY LIVER MR PELVIS ORGAN (specify in comments) BONE MR ANGIOGRAM INTRACRANIAL CAROTID AORTA THORACIC RENAL LOWER EXTREMITY RUNOFF OTHER (specify in comments) OTHER (specify in comments)
HISTORY OF METAL IN BODY OR EYES?      Where:
Weight:

CT:
EXAM1:   - Select One - HEAD SINUS (comprehensive) TEMPORAL BONE NECK (soft tissue) LARYNX CHEST HIGH RES CHEST (HRCT) ABDOMEN PELVIS ABD/PEL (complete) CT ENTEROGRAPHY IVP W/3D RECON SPINE SPINE W/3D RECON CERVICAL SPINE THORACIC SPINE LUMBAR SPINE LEFT EXTREMITY RIGHT EXTREMITY EXTREMITY W/3D RECON OTHER (specify in comments) CT ANGIOGRAM PULMONARY ANGIOGRAM INTRACRANIAL CAROTID AORTA THORACIC AORTA ABDOMINAL LOWER EXTREMITY RUNOFF RENAL OTHER (specify in comments) OTHER W/3D RECON	EXAM2:   - Select One - HEAD SINUS (comprehensive) TEMPORAL BONE NECK (soft tissue) LARYNX CHEST HIGH RES CHEST (HRCT) ABDOMEN PELVIS ABD/PEL (complete) CT ENTEROGRAPHY IVP W/3D RECON SPINE SPINE W/3D RECON CERVICAL SPINE THORACIC SPINE LUMBAR SPINE LEFT EXTREMITY RIGHT EXTREMITY EXTREMITY W/3D RECON OTHER (specify in commnets) CT ANGIOGRAM PULMONARY ANGIOGRAM INTRACRANIAL CAROTID AORTA THORACIC AORTA ABDOMINAL LOWER EXTREMITY RUNOFF RENAL OTHER (specify in comments) OTHER W/3D RECON	EXAM3:   - Select One - HEAD SINUS (comprehensive) TEMPORAL BONE NECK (soft tissue) LARYNX CHEST HIGH RES CHEST (HRCT) ABDOMEN PELVIS ABD/PEL (complete) CT ENTEROGRAPHY IVP W/3D RECON SPINE SPINE W/3D RECON CERVICAL SPINE THORACIC SPINE LUMBAR SPINE LEFT EXTREMITY RIGHT EXTREMITY EXTREMITY W/3D RECON OTHER (specify in comments) CT ANGIOGRAM PULMONARY ANGIOGRAM INTRACRANIAL CAROTID AORTA THORACIC AORTA ABDOMINAL LOWER EXTREMITY RUNOFF RENAL OTHER (specify in comments) OTHER W/3D RECON
LEVEL:             LEVEL:            LEVEL:

ULTRASOUND:
EXAM1:   - Select One - OB COMP w/Transvag as ind OB LIM w/Transvag as ind OB w/ Doppler ABD COMPLETE ABD LIMITED (single organ) PEL COMP w/Transvag as ind PEL LIM w/Transvag as ind PEL w/ Doppler AORTA THYROID KIDNEY/BLADDER KIDNEY TRANSPLANT TESTES RETROPERITONEAL OTHER	EXAM2:   - Select One - OB COMP w/Transvag as ind OB LIM w/Transvag as ind OB w/ Doppler ABD COMPLETE ABD LIMITED (single organ) PEL COMP w/Transvag as ind PEL LIM w/Transvag as ind PEL w/ Doppler AORTA THYROID KIDNEY/BLADDER KIDNEY TRANSPLANT TESTES RETROPERITONEAL OTHER	EXAM3:   - Select One - OB COMP w/Transvag as ind OB LIM w/Transvag as ind OB w/ Doppler ABD COMPLETE ABD LIMITED (single organ) PEL COMP w/Transvag as ind PEL LIM w/Transvag as ind PEL w/ Doppler AORTA THYROID KIDNEY/BLADDER KIDNEY TRANSPLANT TESTES RETROPERITONEAL OTHER

WALK-IN EXAMS:

EXAM1:   - Select One - CT LIMITED SINUS CT KUB (FOR KIDNEY STONES ONLY)

DRAW CREATININE: YES NO DATE:  LEVEL:

CONTRAST:        RAD DISCRETION       WITH CONTRAST       WITHOUT CONTRAST

CLINICAL DIAGNOSIS/AREA OF INTEREST:

SYMPTOMS:

COMMENTS:

PRIMARY INSURANCE INFORMATION:

NAME OF INSURANCE: 

PHONE #: 

SUBSCRIBER NAME: 

SUBSCRIBER ID: 

CLAIM/GROUP#: 

INSURANCE AUTHORIZATION REQUIRED:  YESNO   AUTH.# 

 

SECONDARY INSURANCE INFORMATION:

NAME OF INSURANCE: 

PHONE #: 

SUBSCRIBER NAME: 

SUBSCRIBER ID: 

CLAIM/GROUP#: 

INSURANCE AUTHORIZATION REQUIRED:  YESNO   AUTH.#