Diagnostic Imaging Referral Form Page 2
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2pRepaRations
To learn more about your exam go to
q RaDiologic exams
q ct exams (computed tomography)
Barium EnemalAir Contrast Barium Enema: requires bowel prep. If you
All CT scans of the brain, neck, chest, abdomen, pelvis and CT
received bowel prep instructions from your referring physician, you may
angiography potentially involve the administration of intravenous
use them. Otherwise, contact RAPA for special bowel prep instructions.
contrast/dye. These patients should not eat or drink 2 hours prior to
appointment time. Patients scheduled for these studies should be
IVP/GI/Small Bowel Series: Do not eat, drink or chew gum after midnight.
screened for the following as additional prep may be required:
Bone Density scan: No IV contrast, Barium Studies or Nuclear
q Age 65 or over (BUN and Creatinine within the last 3 months)
Medicine studies for 72 hours prior to study. Stop calcium supplements
Insulin-dependent diabetic (BUN and Creatinine within the last
24 hours prior to study.
3 months)
q History of renal insufficiency (BUN and Creatinine within the
HSG, Arthrograms or IVPs should be screened for allergies to X-ray
last 3 months)
contrast. In some cases pre-medication may be necessary. Recent (last
q History of allergy to X-ray contrast (pre-medication may be
3 months) BUN and Creatinine will be necessary for patients 65 or over,
required)
insulin-dependent diabetics, or a history of renal insufficiency.
q Diabetics on Metformin, Glucophage or Glucovance (will need
referring physician to discontinue these meds for 48 hours
q UltRasoUnD exams
following IV contrast)
Ultrasound of Abdomen (Gall Bladder, Pancreas, Liver, Aorta) Do not eat,
drink or chew gum after midnight.
CT Extremities, Joints, Cardiac Scoring and Spine generally do not
require IV contrast and therefore no special preparation is necessary.
Thyroid–Scrotum–Breast: No preparation required
q mammogRaphY
Pelvis, Pregnancy less than 14 weeks: Patients must have a full bladder.
You should finish drinking 48 ounces of fluid 1 hour prior to your
Screening or Diagnostic: No powder, perfume or deodorant in underarm
appointment time. Patients should not empty their bladder after they
area
have started drinking.
History of previous mammograms: When? Where?
Pregnancy greater than 14 weeks: Patients must have a full bladder.
Breast Ultrasound: No preparation required
You should drink 32 ounces of fluid 1 hour prior to appointment time.
For Aspirations/Biopsies: contact office for special instructions.
Do not empty bladder after starting to drink.
Vascular Studies/Carotid, Arterial and Venous Doppler: No preparation
q special seRVices
required
The Contact Numbers listed on the front page will be able to supply any
Renal: No food 2 hours before appointment
necessary preparation instructions and/or information necessary.
TARGET SHOPPING CENTER
Target
(West Entrance)
West Little Rock
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