w/o w w & w/o 70450 70490 70480 70486 70450 70490 72125 72128 72131 71250 74150 74176 72192 73200 73700 q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q 70470 70492 70482 70488 70470 70492 72127 72130 72133 71270 74170 74178 72194 73202 73702 76376 q q q q q q q q q q q q q q q q Patient Appointment Date & Time Exam Requested Physician Name Physician Signature 7800 66TH ST. North #106 • Pinellas Park, FL 33781 Tel: (727) 545.9MRI (9674) • Fax (727) 545.9454 SERVICE • QUALITY • COMFORT TAMPA BAY IMAGING MRI Brain Neck Abdomen Renal Pelvis Other CT q q q q q q Head w/3D (Circle of Willis) Neck Contrast w/3D (Carotids) Chest - Pulmonary Embolism w/3D Chest - Thoracic Aorta w/3D Abdominal Aorta w/3D Pelvis w/3D Abdomen w/3D Upper Extremity w/3D Lower Extremity w/3D Iliofemoral Runoff w/3D q q q q q q q q q q Brain (Head) Pituitary Orbits Sinuses Temporal Bones Neck-Soft Tissue Cervical Spine Thoracic Spine Lumbar Spine Chest Pelvis Upper Extremity Abdomen Abd / Pel Lower Extremity Other q q q q q q q q q q q q q q q q 70544 70547 74185 74185 72198 q q q q q 70545 70548 74185 74185 72198 q q q q q 70546 70549 74185 74185 72198 q q q q q w/o w w & w/o MRA Brain Orbits IACs Pituitary Sinuses TMJ Neck-Soft Tissue (palpable mass) Brachial Plexus Cervical Spine Thoracic Spine Lumbar Spine Chest MRCP Pelvis Shoulder Elbow Wrist Hand Hip Femur/Thigh Tib/Fib Knee Abdomen Ankle Foot Other q q q q q q q q q q q q q q q q q q q q q q q q q q CTA 70551 70540 70540 70551 70540 70336 70540 71550 72141 72146 72148 71550 74181 S8037 72195 73221 73221 73221 73218 73721 73718 73718 73721 73721 73718 q q q q q q q q q q q q q q q q q q q q q q q q q 70552 70542 70542 70552 70542 70336 70542 71551 72142 72147 72149 71551 74182 S8037 72196 73222 73222 73222 73219 73722 73719 73719 73722 73722 73719 q q q q q q q q q q q q q q q q q q q q q q q q q 70553 70543 70543 70553 70543 70336 70543 71552 72156 72157 72158 71552 74183 S8037 72197 73223 73223 73223 73220 73723 73720 73720 72723 73723 73720 q q q q q q q q q q q q q q q q q q q q q q q q q Right Right Right Right Right Right Right Right Right Right Right Left Left Left Left Left Left Left Left Left Left Left i-STAT q 70496 70498 71275 71275 75635 72191 74175 73206 73706 75635 q q q q q q q q q q w/o 82565 q DIRECTIONS: Please see reverse side for maps and directions to Tampa Bay Imaging as well as important information about your exam! X-RAY Abdomen (KUB) Ankle - 2 Views Ankle - Complete Cervical - 2 Views Cervical - 4 Views Cervical -Complete Chest Clavicle Coccyx Elbow - 2 Views Elbow - Complete Facial Bones Femur Finger - Digit ______ Foot - 2 Views Foot - Complete Forearm Hand Hip Unilateral One View Hip Knee - 2 Views Knee - 3 Views Other q q q q q q q q q q q q q q q q q q q q q q q Right Left qq Knees - 4 Views Lumbar Lumbar - Complete Mandible - (PA & LAT) Mandible - Complete Nasal Bone - Complete Orbits Pelvis Ribs Sacral Joint Sacrum Scapula Shoulder Shoulder - 2 Views Sinuses - Waters View Sinuses - Complete Skull Tibia / Fibula Thoracic - 2 Views Thoracic - 3 Views Wrist - 2 Views Wrist - Complete q q q q q q q q q q q q q q q q q q q q q q i-STAT Other Impressions: Special Instructions: CPT CODES CPT CODES w w & w/o w/o CPT CODES q q q q q q q q q q q q q q q q q q q q q q Right Right q q 70460 70491 70481 70487 70460 70491 72126 72129 72132 71260 74160 74177 72193 73201 73701 3D Recon Left Left q q Right Right q q Left Left q q