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Tax ID Number 58-1966795
Imaging Services Scheduling
Phone: 404.501.2660
FAX orders to: 404.501.1743
Patient name:_________________________________________________________
Daytime phone number:
Cell:
Appointment date/time:
DOB:
Referring physician (please print):
Physician signature:
Today’s date:
SPECIAL REQUESTS Please check all that apply
STAT call report #:
FAX (if different than AutoFAX#):
CT
Reason/symptom (no r/o*):
Contrast: Without
With
With and without
BUN: ______ Creatinine:______.
*Required before IV contrast for all patients 65 and over or with a
history of diabetes, renal insufficiency or compromise.
Abdomen
Renal stone protocol
Pelvis
Sinus
Head
CTA head
Chest
CTA urogram/renal
High resolution chest
CTA neck
Soft tissue neck
CTA pulmonary embolism
AAA protocol
Other:
Special protocols:
MRI
Reason/symptom (no r/o*):
Contrast:
Without
With
With and without
GFR______ *required before IV contrast on all patients.
For patients receiving contrast, glomerular filtration rate is required.
MRI brain
MRA brain
Lumbar spine
Cervical spine
Knee
Thoracic spine
Left
Right
Shoulder
Pelvis
Left
Right
Abdomen
Breast
Please specify organ for MRI abdomen:
MR angiography (specify):
Other:
ULTRASOUND
Reason/symptom (no r/o*):
Abdomen
Echocardiogram
Pelvic
Specialists:
Pelvic with transvaginal
Thyroid
Carotid
BPP
Arterial blood flow
Renal
Upper
Lower
OB
Venous blood flow
Abdominal wall mass
Upper
Lower
Extremity
Other:
NUCLEAR MEDICINE
Reason/symptom (no r/o*):
Thyroid uptake and scan
Dual isotope heart scan
Bone scan
Whole body
3 phase
Renal
Lung
Other:
PET/CT
Reason/symptom (no r/o*):
DMC Form # 40026PDF ( Rev. 02/09 )
Please check correct choice:
Patient already scheduled
Please call patient to schedule
Patient will call to schedule
Should DeKalb Medical pre-cert this
procedure on behalf of the physician?
Yes
No
Patient Ins. Carrier & ID #:
Pre-cert # (if necessary):
Physician Tax ID:
Send films with patient
CD images
MAMMOGRAPHY / BREAST ULTRASOUND
Reason/symptom (no r/o*):
Screening mammogram
Bilateral
Unilateral
R
L
Diagnostic mammogram
Bilateral
Unilateral
R
L
Breast ultrasound
Bilateral
Unilateral
R
L
Other:
BONE DENSITY (For osteoporosis)
Reason/symptom (no r/o*):
Heel scan
DEXA Axial Skeleton
Vertebral Assessment (VFA)
INTERVENTIONAL RADIOLOGY (pls. attach lab specimen sheet)
Reason/symptom (no r/o*):
Arteriogram (specify type):
Venous procedure (specify type):
Embolization (specify type):
Biopsy (specify type):
Drainage (specify type):
Other:
ROUTINE X-RAY
Reason/symptom (no r/o*):
Chest, PA and lateral
Flat abdomen (KUB)
Acute abdominal series
Cervical spine
Thoracic spine
Lumbar spine
Bone survey (multiple myeloma or mets)
Ribs
Extremity:________________
Left
Right
Left
Right
Other:
FLUORO
Reason/symptom (no r/o*):
Barium swallow
Barium enema
Barium enema — air contrast
Upper GI series
Small bowel series
Hysterosalpingogram
Arthrogram (specify site):
Other:
GU TRACT
Reason/symptom (no r/o*):
IV pyelogram
Cystogram, voiding
Other:
EKG
EKG
Stress test
Rhythm strip
Holter monitor
Other:
EEG
Reason/symptom (no r/o*):
EEG
BHER
Sleep EEG
VEP
SSEP
Comments:
*No rule out.
Bring this form, completed and signed by your physician, and your insurance card
with you to the facility registration/testing area. Arriving for testing without this
form signed by your physician may result in cancellation or delay of your test.
Employee Parking
Computed Tomography (CT)
• Chest: Nothing to eat 4 hours prior to
test. Bring recent chest X-rays or scans for
correlation if not taken at DeKalb Medical.
• Abdomen: Nothing to eat or drink except
barium 4 hours prior to exam. Drink
1 jug of barium (available in Diagnostic
Imaging Center or Diagnostic Imaging
Department at Hillandale) 2 hours prior
to appointment time. You will be given
another cup to drink before your scan.
• Pelvis: Nothing to eat or drink 4 hours
prior to appointment. Drink 1 jug of
barium 2 hours prior to appointment.
• Renal stone protocol: No prep.
*Iodine contrast injection required for most
studies. Recent BUN and creatinine needed
on patients 65 and older; patients with any
history of renal problems, including diabetes,
A
Emerge
ncy
Entrance
Circular Drive
Entrance
Bill Thrasher Drive
Employee Parking
Pe
d
Br estri
idg an
e
The Women's
Center
Wash Lively Circle
Visitor
Central Registration
• Pelvis or OB: Female patients should
Parking
Main Hospital Entrance
Deck
drink 32 oz. of water one hour prior to
s Drive
Rufus Evan
exam. Bladder must be full for the test. Do
C D
B
not empty your bladder prior to the test.
• Abdomen (gallbladder, liver, pancreas,
North Decatur
Road
spleen and aorta):Nothing by mouth
8 hours prior to the exam.
A. Main hospital building
• Carotid or venous doppler: No prep.
B. Diagnostic Imaging Center
• Thyroid: No prep.
C. 2675 Professional Building
Wash LivelyCircle
• Barium swallow: No prep.
• Upper GI series: Nothing to eat or drink
after midnight.
• Barium enema: *Diabetics consult with
your physician for special instructions.
Two days before the exam: Light
breakfast and lunch. Drink at least 3
glasses of water or fruit juice throughout
the day. Limit the evening meal to clear
soup, such as bouillon, plain Jell-O
without fruit, apple juice, soft drinks,
coffee or tea. NO MILK.
One day before the exam: No solid
foods. Clear liquid diet. No milk or fats.
During the day drink at least 4 glasses
of water. At 7 p.m. take 3 tablespoons of
Phospho-soda (available in any
pharmacy) in a glass of cold water
followed by a half glass of cold water.
Plain water enema (one quart or more)
at bedtime.
Morning of exam: Do not eat anything
until after the exam. Plain water enema
in early a.m. Repeat until it returns clear.
Enemas should be complete at least 1
hour before going for appointment.
• IVP: Same prep as Barium Enema.
*Diabetics consult with your physician for
special instructions.
p
Emergency Ram
Ambulance
Entrance
Drive
Ultrasound (US)
Restricted Patient Parking
Employee
Parking
Sycam
ore
X-ray/Fluoroscopy
DeKalb Medical at North Decatur
Sowell Street
Additional information can be found at
www.radadpc.com.
high blood pressure, multiple myeloma,
renal failure or obstruction; patients with
only one kidney or polycystic kidneys; or
patients receiving chemotherapy.
Winn Way
Imaging Services Preparation
Instructions for Adult Patients
Cancer
Center Entrance
The Wellness
Center Entrance
E
1045
Building
Ch
ur
ch
et
re
St
D. 2665 Professional Building — Breast Center
Mammography: Do not wear deodorant E. 1045 Surgical Weight Loss Center
or powder the day of your exam.
DeKalb Medical Diagnostic Imaging Center
2701 North Decatur Road, Decatur, GA 30033
MRI: Patients who have a pacemaker or Phone: 404.501.2650 Fax: 404.501.4951
Diagnostic Breast Center
aneurysm clip may not have an MRI. For
2665 N. Decatur, Suite 120, Decatur, GA 30033
patients receiving contrast, glomerular
filtration rate is required for those with renal Phone: 404.501.5678 Fax: 404.501.1855
Radiology — M ain Hospital
disease or compromised renal function.
2701 North Decatur Road, Decatur, GA 30033
Phone: 404.501.5286 Fax: 404.501.3292
Nuclear Medicine
• Thyroid: Thyrogen or I 131 whole body
scan: Low iodine diet for 5 days prior to
exam. No seafood, no extra salt for 5
days prior to exam. Must be off all thyroid
medication for 6 weeks prior to exam .
No IV contrast 8 weeks prior to exam.
• Thyroid uptake & scan: See thyroid
prep above. Exam may take 2 or possibly
3 appointments. Day one includes a
15-minute appointment in the a.m. Return
visit 5 – 7 hours later for a 45-minute
appointment. Possible third 10-minute
appointment in the a.m. of the second
day.
• Bone scan: Drink fluids in the morning of
the appointment. Two-appointment
process. Receive injection in the a.m.,
15-minute appointment. Return approximately 3 hours or more for scan, 1-hour
appointment.
• Hida scan (gallbladder): Nothing to eat
or drink after midnight the night before
your exam. Total procedure time is
approximately 2 – 24 hours. Can be a
2-day exam.
• Gastric emptying: Nothing to eat or
drink after midnight. Total exam time is
approximately 2 ½ hours.
DeKalb Medical at Hillandale
Fountain
3
1 2
A
C
B
A. Main hospital building
1. Imaging Department
2. Emergency Department
3. The Bistro
B. 5900 Professional Building — B reast Center
C. 5910 Professional Building
DeKalb Medical at Hillandale Breast Center
5900 Hillandale Dr., Ste. 155, Lithonia, GA 30058
Phone: 404.501.8020 Fax: 404.501.8138
Imaging Department
2801 DeKalb Medical Pkwy., Lithonia, GA 30058
Phone: 404.501.8478 Fax: 404.501.8027
For additional maps and directions, visit
www.dekalbmedical.org