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APPOINTMENT INFORMATION GENERAL DIAGNOSTIC RADIOLOGY APPOINTMENT SCHEDULING: 703.824.3260 alexandriaradiology.com You must bring this form to your appointment Date_________________ Time_________________ Location_____________________________________ PLEASE CALL THE PATIENT TO SCHEDULE PLEASE FAX THIS FORM TO 703.995.4425 Patient Name ____________________________________________________________ PATIENT’S PHONE (H or C) _____________________________ (W) _____________________________ Physician _______________________________________ Telephone __________________________ Date ___________________________ Signature Required ______________________________________________ Fax __________________________ Report Copies to ____________________________ Additional Clinical Information: ________________________________________ For Insurance Precertification Support: P 703.824.3227 F 703.995.4425 ICD-9 Code _______________________ Precert./Auth. No _______________________ STAT Wet Read, Phone # _____________________________ Important Finding, Phone # _______________________ Send with Patient: Film CD I authorize Association of Alexandria Radiologists to add or delete any additional imaging procedures that are required to appropriately diagnose the patient I am referring. DIAGNOSTIC X-RAY No Appointment needed Chest PA/LAT PA only Supine Flat/Erect Abdomen DIGITAL MAMMOGRAPHY Screening/CAD Asymptomatic 3D Mammogram Tomography Conditional Orders: F/U comprehensive mammogram w/breast ultrasound, as indicated Diagnostic/CAD Symptomatic FLUOROSCOPY (WIC ONLY) Arthrogram Joint: __________________________ HSG ULTRASOUND OB ___ 1st ___ 2nd ___ 3rd Trimester Nuchal Trans w/ PAPP A & Free Beta Bio-Physical Profile Pelvic - Transabdominal Ribs RT___ LT___ BILAT___ KUB Cervical Spine Sinus T-Spine L/S-Spine Pelvis Sacrum/Coccyx Hip RT___ LT___ Shoulder RT___ LT___ Humerus RT___ LT___ Elbow RT___ LT___ Forearm RT___ LT___ Wrist RT___ LT___ Hand RT___ LT___ Finger RT___ LT___ Femur RT___ LT___ Knee RT___ LT___ Lower Leg RT___ LT___ Ankle RT___ LT___ Foot RT___ LT___ Toe RT___ LT___ Other ___________________________ _____________________________________ ____________________________________ _____________________________________ Carotid Doppler, Bilateral Venous Doppler ____________________________________ _____________________________________ Renal Arterial Doppler (WIC only) RT___ LT___ BILAT___ Breast Sono as indicated Conditional Orders: Biopsy or cyst aspiration, as indicated BIOPSY Stereotactic Breast Biopsy RT___ LT___ BILAT___ Ultrasound Biopsy RT___ LT___ BILAT___ Cyst Aspiration DEXA Bone Density Scan DEXA w/IVA/VFA Body Composition (WIC only) OTHER REQUEST Transvaginal as indicated Transvaginal Abdominal – Complete, Doppler as indicated Bladder Renal Thyroid Testicular, Doppler as indicated Hysterosonogram-Saline Infusion Menopausal Breast YES___ NO___ RT___ LT___ BILAT___ INFANT & NEONATAL ULTRASOUND Neonatal Hip RT___ LT___ Neonatal Spine Neonatal Pyloric Stenosis VASCULAR ULTRASOUND Upper Extremity Lower Extremity SCHEDULING INSTRUCTIONS AAR APPOINTMENT SCHEDULING: 703.824.3260 236 ARLINGTON LIT TL E TURN 495 IA N I VIRG RIVER 1 7 BRA D 395 PIKE N VA RN DO . ST SEMIN DUK E ST. ARY RD . SHERWOOD HALL LN. SPRINGFIELD 95 4660 Kenmore Avenue Suite 525 Alexandria, VA 22304 Appointment Scheduling: 703.824.3260 DO C K RD . ALEXANDRIA HYBLA VALLEY AAR Alexandria Imaging Center Inova Alexandria Hospital Cardiovascular and Interventional Radiology 4320 Seminary Road Alexandria, VA 22304 Appointment Scheduling: 703.504.7950 PARKER’S LN. 1 Inova Mount Vernon Hospital Cardiovascular and Interventional Radiology LORTON OCCOQUAN 95 PRINCE WILLIAM PKWY 1 Sentara Northern Virginia Medical Center, Heart and Vascular Center 2300 Opitz Boulevard Woodbridge, VA 22191 Appointment Scheduling: 703.523.1980 2501 Parker’s Lane Alexandria, VA 22306 Appointment Scheduling: 703.664.7462 WOODBRIDGE IMPORTANT PATIENT INFORMATION FOR YOUR APPOINTMENT 1. Children are not permitted to accompany a patient to the examination room and may not be left unattended in the waiting room. Please plan accordingly. 2. On the day of your appointment, be sure to bring: This form (it is your doctor’s order) Your insurance card and a photo ID Your copay All previous mammography studies 4001 Prince William Parkway Suite 302 Woodbridge, VA 22193 Appointment Scheduling: 703.824.3260 All other previous studies and reports related to your condition Any appointment forms you have completed EXAM PREPARATION INSTRUCTIONS Mammogram Please do not use deodorant, perfume or powder on the underarms or breast area the day of the exam. Bring previous mammograms for comparison – if not performed at AAR. DEXA/Bone Density Do not take calcium supplements 24 hours R Y A DALE BLVD AAR Woodbridge Imaging Center M OPITZ BLVD ND A L prior to the exam. If you have had, or are scheduled to have, an exam requiring barium or contrast, it must be completed at least 7 days prior to your bone density appointment. Ultrasound —Abominal, Aortic, or Gallbladder Please do not eat or drink 8 hours prior to your exam. Do not chew gum or smoke 8 hours prior to your exam. Ultrasound - Pelvic, Renal, Obstetrical or Bladder Please empty bladder and finish drinking 24 oz. clear fluid (water, apple juice, tea) one hour prior to exam. Do not empty your bladder until the exam is complete. VISIT ALEXANDRIARADIOLOGY.COM FOR EXAM INFORMATION, DIRECTIONS AND REGISTRATION FORMS.
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