Download Come Prepared - Inglewood Imaging Center

INGLEWOOD IMAGING CENTER • EXAM REQUISITION
211 North Prairie Ave #E
Inglewood, CA 90301
phone: 310-672-9729
fax: 310-672-9720
Please visit our website:
www.inglewoodimaging.com
CT
MRi
CT ANGIO
MRi ANGIO
X-RAY*
Ultrasound*
DEXA*
Nuclear Med*
Cardiac N.M.*
Patient Name:
Date of Birth:
Patient Phone: (DAY)
(EVENING)
Diagnosis:
SCHEDULING QUESTIONS
IV Contrast OK?
Diabetic?
Tuberculosis?
Pregnant?
Left/Right?
Height:
Weight:
PET/CT
YES NO
Exam Requested:
BUN:
Date:
Creatine:
Physician:
Phone:
Physician Signature:
Patient Instructions:
Send copy of report to:
Dr.
PCP:
FAX #
Appointment Date:
Time:
Come Prepared:
211 North Prairie Ave #E
Inglewood, CA 90301
EXAM
FAST
INSTRUCTIONS
CT
6 hours
6 hour fasting (for contrast studies only).
You may continue drink clear fluids.
DEXA
none
Wear comfortable clothing without
metal objects.
MRi & MRA
none
(Cat Scan)
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Inglewood
Imaging Center
W. Manchester Blvd
211 N. Prairie Ave
E. Regent St
Nuclear Med. none
(General)
Nuclear Med. 12AM
W. Manchester Blvd
“*” denotes services scheduled by IIC, LLC on behalf of ICM
Medical Group. Inc.
Please call to confirm. Usually no
special preparation is needed.
Avoid caffeine (coffee, tea, soda,
chocolate, etc) and smoking for 48 hours
before the examination. No aspirin.
(Cardiac)
(midnight)
PET/CT
6 hours
Low-carbohydrate diet 24 hours prior
with 6 hours fasting. No food of any kind
during fasting period (including snacks,
gum, mints). No strenuous exercise
for 24 hours. Drink lots of water.
Ultrasound
6 hours
Nothing to eat 6 hours prior to exam.
none
An hour before your appointment, drink
4 large glasses of water. Please do not
empty bladder before appointment.
none
none
Hollywood Park
Race Track
Note: Please arrive 30 minutes prior to your exam. Please bring
copies of your driver’s license, insurance card, prior exams/history
& exam pre-authorization (or pre-certification) with you. In case
we do not contact you prior to your exam, please call our office
by 3:00 pm one day prior at 310-672-9729.
No metal objects (including:
pacemakers, metal rods, hearing aids.
Wear comfortable clothes.
(abdomen)
Ultrasound
(Pelvic)
X-RAY