Imaging Referral Form printable pdf download

Main number (602) 933-1213

All Information

Radiology Scheduling (602) 933-1215 • Fax: (602) 933-1214

MUST BE COMPLETE

Interventional Scheduling (602) 546-4444 • Fax: (602) 933-1587

in Order to Process Referral

Imaging Referral Form

PATIENT INFORMATION:

Please bring this form with you to your appointment

Parent/Guardian Name ______________________________________________________________________________________

Child’s Name_______________________________________________________________Date of Birth_____________________

Day Phone________________________________Evening Phone____________________________Today’s Date ____________

Insurance_____________________________________________________________Authorization #________________________

Referring Physician________________________________________Referring Physician Phone #________________________

Referring Physician Fax #_____________________Contact person from Doctor’s office________________________________

Patient’s weight_____________________________

 Male  Female

Language Spoken ______________________________

 URGENT

 STAT

 ROUTINE

LOCATIONS:

 Phoenix Children’s Hospital

 Phoenix Children’s

1919 E. Thomas Rd.

Specialty and Urgent Care

Phoenix, AZ 85016

East Valley Center

Northwest Valley Center

5131 E. Southern Ave.

20325 N. 51st Ave., Suite 116

Mesa, AZ 85206

Phoenix, AZ 85308

(X-ray only at this location)

EXAM REQUESTED

 SEDATION

 GENERAL ANESTHESIA

X-RAY (Please be specific)

ULTRASOUND

 Chest (1 view)

 Head***

Contrast (specify)

 Chest (2 views)

 Renal (Kidney)***

 w/cont

 w/o

 w & w/o

 Sinus -

view

 Abdomen (Complete or Limited)***

 Skull -

view

 Pelvis***

Sedate (specify)

 Neck (soft tissue)

 Hip***

 with  w/o  general

 Spine -

view

 Pyloric***

 Scoliosis

 Testicular/Pelvic Doppler***

 Sinus***

 Upper Extremity view/side (specify

 Other***

 Head***

below)

 Chest***

 Lower Extremity view/side (specify

NUCLEAR MEDICINE*

 Abdomen/Pelvis***

below)

 Bone Scan (Whole Body)***

 Pelvis***

 Extremity view/side

 GFR***

 Other (specify)***

 Other –

 MAG-3***

MRI

 Barium Enema (BE)***

 Gastric Emptying (Liquid or Solids)***

Contrast (specify)

 Upper GI (UGI)***

 DMSA***

 UG/Small Bowel***

 Other***

 w/o

 w & w/o

 Voiding Cystourethogram (VCUG)***

 Modified Barium Swallow (with

CT PET (FD6)

Anesthesia (specify)

speech)***

 Whole Body

 with  w/o

 general

 DEXA***

 Eyes to Thighs

 Other

 Brain

 Head***

 Other Non-radiology Outpatient Tests

 C11 Brain

 Spine (specify below)***

 Other (specify below)***

Ordered

*** Scheduled examination, must be scheduled with Imaging in advance

SPECIAL NEEDS:

HISTORY:

WRITTEN DIAGNOSIS



Check here if additional clinical information is included with this order

PHYSICIANS/PA/NP SIGNATURE:_____________________________________________________________________________

Imaging Referral Form

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