PHYSICIAN SIGNATURE: RADIOGRAPHIC STUDIES PET / CT FLUOROSCOPY ULTRASOUND STUDIES INTERVENTIONAL RADIOLOGY Patient to Call Call Patient to Schedule--Patient Phone #_________________________Cell:___________________ Insurance Carrier:________________________________________Auth. #__________________________Auth. Facility__________________________ DOB________________ Diagnosis/Signs/Symptoms____________________________________ NUCLEAR MEDICINE LUMBAR PUNCTURE MRI CT MRI CT MRI CT MRI CT MRI CT MRI CT MRI CT MRI CT Central Scheduling PHONE: 704-384-7226 Scheduling Fax: Imaging Center: 704-384-8511 / Hospital: 704-316-9327 HEAD/NECK Head Brain Brain Lab Protocol Seizure Protocol Functional IAC Pituitary Orbits Neck (Soft Tissue) TMJ BODY Chest Brachial Plexus Abdomen Pelvis Bony Female Male MRCP Breast R L B Breast Biopsy Prostate Adrenal Kidneys Enterography Other________________ SPINE Cervical Thoracic Lumbar Sacrum Arthrogram Joint__________________ CARDIAC Morphology/Function + Stress MRI ANGIOGRAM Head Neck Chest Abdomen Runoff _____________________ ___________________________ Sedation GENERAL* *only at PH Contrast: With & Without Without Rad Discretion HEAD/NECK Head / Brain Temporal Bone Orbits Neck (Soft Tissue) Facial Bones Sinus Sinus Mini SPINE Cervical Thoracic Lumbar CT Screening CT Cardiac Scoring CT Lung Screening CT Biopsy Lung Abdominal Bone CT Myelogram Cervical Thoracic Lumbar FNA FNA FNA Core Core Core CARDIAC CT Coronary Angio Pulmonary Veins Congenital BODY Chest Chest - HIGH RES Abdomen Pelvis Abd & Pelvis Chest/Abd/Pelvis CT Enterography Renal Renal-Stone Protocol CT Urogram Adrenal Chest/Abdomen/Pelvis CT Colonography CT ANGIOGRAM Head / Brain Neck Thoracic / Chest PE Protocol Abdomen / Renal Abdomen / Pelvis Mesenteric Upper Extremity R L Lower Extremity R L Runoff_____________ Contrast: With Without Rad Discretion Bone Scan Bone Scan w/ SPECT 3 Phase Bone Scan 3 Phase Bone Scan w/ SPECT Gastric Emptying Scan HIDA Scan with EF V/Q Scan Renal Scan MUGA (Gated Heart) Nuclear Stress Test I-131 Therapy I-131 Post-Therapy Scan I-131 Whole Body Scan I-131 Thyrogen Stimulated Therapy I-131 Thyrogen Stimulated Whole Body Scan Thyroid Scan Only Thyroid Uptake Only Thyroid Uptake & Scan I-123/Sestamibi Parathyroid SPECT Parathyroid Scan Parathyroid SPECT Other________________ _____________________ w/UGI Prior Imaging: When?_____________________ Where?_____________________ LAP BAND ADJUSTMENT MBS w/ VIDEO HIP INJ/ASPIRATION HSG #:________________________________________________________________________ _______________________________________________________________________________________________________________ DEXA - Bone Densitometry X-Ray_______________________________________ Abdomen Abdomen / Pelvis/Endovag Pelvis / Endovag Pediatric Patient / Pelvis US Liver RUQ / Gallbladder Aorta Carotids Carotid IMT Transcranial Thyroid Scrotal w/ Doppler Prostate Hips Neck-soft tissue Soft Tissue_______ Renal___________ Prostate Biopsy PSA Level____ DVT Upper R L B DVT Lower R L B Arterial Doppler Upper R L B Arterial Doppler Lower R L B Venous Mapping R L B Renal Artery Doppler Infant Spine Thoracentesis Paracentesis Biopsy Thyroid Liver Renal Skull Base to Thigh Whole Body Brain Cardiac Viablity F18 Bone Scan 3-D Reconstruction w/AIR w/o AIR referring Rad RT LT Other:_________ ______________ ________________________________________________________________