Medical Evaluation Form Scan

John F. Feller MD

Christopher R. Hancock MD

Stuart T. May MD

Adam J. Brochert MD

Scheduling Dept. Ph (760) 694-9559

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Fax (760) 356-8208

Today’s Date________________________________________________________________ Next Office Visit __________________________________

Patients Name:_________________________________________________________________ Date of Birth:____________________ Sex: M___ F ___

Home Number:______________________________ Work Number:_____________________________ Cell Number: ___________________________

Clinical History/Diagnosis: ____________________________________________________________________________________________________

__________________________________________________________________________________________________________________________

Referring Physician:__________________________________________ Phone:_________________________ Fax: ____________________________

Physician Signature: _________________________________________________________________________________________________________

MRI

CT

Ultrasound

Biopsies

Without Contrast

Without Contrast

Abdomen

Liver

Without & With Contrast

Abdominal Hernia

Without & With Contrast

Prostate

(MRI Only)

Abdomen

Aorta

Abdomen

Renal

MRCP

Arterial

Abdomen and Pelvis

Soft Tissue Mass

Brain/Head

Upper (Arm) ___R ___L

Bone Density (Lumbar)

Thyroid

Lower (Leg) ___R ___L

w/ special attention to IAC

Brain/Head

Other:_____________________

Breast ___R ___L

w/ Neuroquant

Chest

Breast Bilateral

Carotid (CIMT)

PET/CT

Extremity ___R ___L

w/ implants

Extremity ___R ___L

Specify body part____________

Specify body part____________

Brain Amyvid

Chest

IAC/Temporal Bone

Gallbladder

Extremity: Joint ___R ___L

FDG-18 Brain Metabolic

Lumbar Tap

Specify body part____________

Liver

FDG-18 Skull Base to Mid Thigh

must include lab instructions

Extremity: Non-joint ___R ___L

Nuchal Translucency

FDG-18 Whole Body - Vertex

Maxillofacial - Facial Bones

Specify body part____________

OB/Fetal

LMP____________

Skull to Toes

Hip ___R ___L

Neck (Soft Tissue);

w/ Endovaginal

NaF-18 Whole Body Bone Scan

___Max. ___Mand.

Neck - Soft Tissue

Pelvic

Other:_____________________

Sinus

Orbits

w/ Endovaginal

Pelvis ___Bony ___Soft Tissue

Spine:

Screening Procedure

Renal

__Cervical __Thoracic __Lumbar

Prostate

(Contrast Required)

Not covered by Insurance

Scrotal (Testicular)

Orbits

Spine:

Thyroid

CT Coronary Angiography*

__Cervical __Thoracic __Lumbar

Pelvis

Urinary Bladder

TMJ ___R ___L ___Bilateral

CT Coronary Calcium Score*

Urogram (Abdomen/Pelvis)

Venous Doppler

Other:_____________________

CT Lung Screening*

Other:_____________________

Upper (Arm) ___R ___L

CT Virtual Colonography*

MR Angiography (MRA)

Lower (Leg) ___R ___L

CT Angiography

CT Whole Body Scan

Other:_____________________

Without Contrast

MRI Whole Body Scan

With IV Contrast

With IV Contrast & 3D Recon

Therapeutic Injections

May be covered by insurance

*

Abdomen/Pelvis

Abdomen/Pelvis

with specific diagnosis

Foot

___R ___L

AIF Runoff

AIF Runoff

Hip

___R ___L

Brain/Head

Aorta ___Renal Arteries

Knee

___R ___L

(IW only)

Coronary Arteries

Brain/Head

Shoulder ___R ___L

Chest

Chest

Spine (Facets)

___Arch ___Thoracic Aorta

Extremity ___Upper ___Lower

__Cervical __Thoracic __Lumbar

Neck/Carotids

Neck/Carotids

Wrist

___R ___L

Upper Extremity ___R ___L

Other:_____________________

Other:_____________________

If Diabetic, please include:

BUN:________________________

Arthography

Creatinine: ___________________

Please fax a copy of the patient’s insurance card(s), and any pertinent

MR

CT

clinical information, with this order. If additional information is needed,

GFR: ________________________

Including CT Guidance Injections

we will contact your office.

Lab Date: ____________________

Elbow

___R ___L

If an exam requires authorization, the authorization must be obtained

Is patient on Dialysis? __________

Hip

___R ___L

before the patient is scheduled.

Knee

___R ___L

Shoulder ___R ___L

Wrist

___R ___L

Insurance Company_____________________________________________________

Other:_____________________

INSURANCE AUTHORIZATION # __________________________________________

Additional Comments/Instructions:_____________________________________________________________________________________________

The information contained herein is confidential and proprietary to Desert Medical Imaging and the addressee. Distributing and/or copying this information by anyone other than the interested recipient, or an employee

or agent responsible for delivering the message to the intended recipient, is prohibited. If you have received this information in error, please contact the sender and destroy the original message and all copies immediately.

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Scheduling Dept. Ph (760) 694-9559

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Fax (760) 356-8208