Outpatient Imaging Orders Form
ADVERTISEMENT
1
2Outpatient Imaging Orders
ATTENTION PATIENTS:
Please remember to bring this form with you to the hospital for your test. Your test may be delayed or cancelled if we do not have this form.
Patient Name __________________________ DOB: __________________
Patient Contact Number: _________________________________________
Diagnosis: ____________________________________________________
Precert needed:
Yes
No
ICD-9 Code: ___________________________________________________
Precert #: _____________________________________________________
Ordering Physician: _____________________________________________
Referral needed:
Yes
No
Physician Phone Number: ________________________________________
STAT Call Report to:
Yes
No #: ______________________________
Physician Signature and Date: _______________________________________________________ NPI #: _______________________________________
ATTENTION PHYSICIAN OFFICES: Please select tests below.
Call Patient to Schedule
CT SCANNING
NUCLEAR MEDICINE
INTERVENTIONAL
Ribs:
R L
With contrast (as specifi ed by Radiologist MD)
Abdomen – KUB
Port Placement
Bone Scan
3 Phase
Chest
Abdomen – Flat, Upright & Chest
Double Lumen PICC Line Placement
Cisternogram
Chest High Resolution (no contrast)
Skull
VAS Cath
Gallium Scan
CT Chest (P.E.) / Dissection
Sinuses
Perma Cath
Gastric Emptying
Abdomen/Pelvis (diaphragm to pubis)
Facial Bones
Arteriogram
GI Bleed Scan
Abdomen (diaphragm to iliac crest)
Nasal Bones
Radio Frequency Ablation (RFA)
Abdomen
Pelvis (iliac crest to pubis)
Cervical Spine
Requires Consult
Lung / VQ Scan
Head
With Flexion / Extension
Specify:
Hemangioma
Consults:
Sinus (axial and coronal)
Obliques
Hepatobiliary Scan
Orbitis
Thoracic Spine
Women’s Imaging
With CCK
Temporal Bone
Lumbar Spine
Cancer Treatment
Liver / Spleen Scan
Neck
With Obliques
Fracture Treatment
Lymphoscintigraphy
Cervical Spine
With Flexion / Extension
Pain Management
Specify:
Thoracic Spine
Sacrum / Coccyx
Port Check - Stripping
MUGA / Ejection Fraction
Lumbar Spine
Pelvis
Replacement, if needed
Parathyroid
Facial Bones
Hip
R
L
Abscess/ Fistula/ Sinus Tube Check
Renal Scan
Extremity
Femur
R
L
Drainage Tube Change – Any Type
With Lasix
Specify:
Knee
R
L
Specify:
Shunt Patency Study
CTA
Lower Leg
R
L
Dialysis Shunt Study/AV Fistulogram
Thyroid Scan and Uptake
Specify:
Ankle
R
L
Biliary Drainage
Thyroid Update Only
Other:
Foot
R
L
Cholangiogram
Thyroid Scan Only
Cardiac Calcium Scoring
Toes
R
L
Myelogram /
Discogram
Therapy for Hyperthyroidism
Lung Screening
Shoulder
R
L
Cervical Level:
Thyroid Therapy:
Creatinine for Contrast
Humerus
R
L
Thoracic
Whole Body Survey (I-131)
Forearm
R
L
Lumbar
White Blood Cell Study
MRI
Elbow
R
L
Percutaneous Nephrostomy
Specify:
With contrast (as specifi ed by Radiologist MD)
Wrist
R
L
R
L
Bilateral
Other:
With sedation
Hand
R
L
Ureterostomy
Brain
Fingers
R
L
R
L
Bilateral
MRA
Specify:
ULTRASOUND
Embolization – Requires Consult
Intracranial / Head
Metastatic Survey
Abdominal
Specify:
Extracranial / Neck
Other:
Abdominal Limited
Lumbar Drain
MRA ABD
Myelogram
IVC Filter Placement
RUQ
AORTA
MRA Runoff
Cervical
Port Removal
Gallbladder
Liver
MRV
Thoracic
Percutaneous Drain Placement
Other:
Neck / Soft Tissue
Lumbar
Specify:
Renal
With Doppler
TMJ
Lumbar Puncture
Arthrogram
Renal Transplant
Brachial Plexus
Specify Details:
Specify:
Pelvic with Transvaginal
Lumbar Plexus
UAE / UFE – Requires Consult
(if needed)
Spine
Testicular
FLUOROSCOPY
MUSCULOSKELETAL
Cervical
Carotid
Thoracic
Esophagram
Tendon Sheath Injection
Thyroid
Lumbar
Hysterosalpingogram
Rt Ankle
Lt Ankle
Venous
UGI
Vertebroplasty
Chest
Upper
Lower
Abdomen
UGI & Small Bowel Series
Acetabuloplasty
Right
Left
Bilateral
Pelvis
Small Bowel Series
Socroplasty
Arterial
Extremities
Barium Enema
Kyphoplasty
Upper
Lower
ABI
Specify:
R
L
IVP
Specify Level:
Right
Left
Bilateral
Non-contrast Breast MRI for Implant Evaluation
Cystogram
Consult Desired
Bladder
Pre & Post Contrast MRI for Breast Cancer
With Voiding Films
Joint Injection
Paracentesis / Thoracentesis
Detection/Staging
Retrograde Urethrogram
Specify:
Diagnostic
MRCP
Arthrogram
with MRI
with CT
Other:
Therapeutic
Specify:
Other:
Bone Density
X-RAY (Plain Films)
Video Swallowing Study
Epidural Injection
Other:
Chest – Single View (PA)
Other:
Nerve Block
Chest – PA & Lateral
Physician Offi ce should obtain precerts for exams scheduled less than 24 hours in advance.
CALL TO SCHEDULE: 678-474-8100
FAX ORDERS TO: 678-474-8101
Physician Signature: _____________________________________________________ Date: _______________ Time: _______________
Patient Information/Label
Outpatient Imaging Orders
FORM CONTINUED ON BACK
0340200952
Page 1 of 2
*IMG*
rev 2/11
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical