Physician Order Form - Imaging Services
ADVERTISEMENT
1
2Physician Order Form – Imaging Services
Diagnostic Imaging Services
3181 S.W. Sam Jackson Park Road, Portland OR 97239
Date:
/
/
Phone: 503-418-0990
Fax: 503-494-4621
PATIENT INFORMATION
Patient Name: ________________________
Date of Birth: _______________________
Patient Phone: _________________________
Please call Patient
Patient will call to schedule
ICD 9 Code: __________________________
: ______________________
Authorization #
Reason for Exam: ____________________
____________________________________
REQUESTING PHYSICIAN INFORMATION
Referring Physician: _______________________
_______
Phone:
Referring Physician Signature:
______________
_______
Results (check all that apply):
E-mail report: (e-mail)
__________________
CD with Images
Fax report: (fax #)
__________________
Special Request:
Phone Report: (phone #)
__________________
EXAM
FOCUS
Brain MRI
Brain MRA
Neck MRI
Neck MRA
MRI
Cervical Spine
Thoracic
Lumbar
w/ contrast
Extremity (specify):
wo/ contrast
Other (specify):
w/wo contrast
Vagal Nerve Stimulator: Program both generator output current and magnet output current to OMA
prior to the MRI procedure. After MRI is completed, re-program device to original settings.
CT
Brain
Sinus
Chest
Abdomen
Pelvis
w/ contrast
Cervical Spine
Thoracic
Lumbar
wo/ contrast
Extremity (specify):
w/wo contrast
Other (specify):
Diagnostic
Screening
Others (specify):
Mammogram
Abdomen
Pelvis
OB/GYN
Ultrasound
Other (specify):
Nuclear Medicine
Bone
SPECT
Thyroid
Liver – Spleen
Head/Neck
Lung
Breast
Lymphoma
PET/CT
Other (specify):
Barium Enema (please select):
With air contrast
Without air contrast
I.V. Pyelogram
Upper G.I. (please select):
With small bowel series
Without small bowel series
General Radiology
Voiding Cystourethrogram
X-ray (specify):
Fluoro Other (specify):
Vascular Lab
Peripheral Arial Exam
Venous
Chronic Venous Exam
PPG’s
Upper Extremity
Transcranial Doppler
Carotid
Temporal Artery
ABI’s with waveform
Lower Extremity
Nielsen Cold Challenge
Graft Flow
Arterial Duplex
Dialysis Graft Eval.
Abdomen (please select):
Finger
Toe(s)
Renal
Mesenteric
Portal Hepatic
AAA
Renal Transplant
Other (specify):
Right
Left
Other
Specify:
Scan to PO-7070
Rev 01/08
Form also available at
HCM 1499758 06/10
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business