Survey
* Your assessment is very important for improving the work of artificial intelligence, which forms the content of this project
Download Referral Form
Document related concepts
no text concepts found
Transcript
Precert./Ref. #’s: Appt. Date/Time: Date Issued: Compassionate Care, Superior Service Since 1960 PATIENT NAME: DATE ISSUED: DOB: DIAGNOSIS (Required): REFERRING DOCTOR: ADDRESS: 9601 Bustleton Avenue, Philadelphia PA 19115 Tel: 215-676-5100 • Fax: 215-676-6332 www.BustletonRadiology.com STAT report Send report (routine) Images on CD Films Patient to return with films Cc report to: REASON FOR EXAM: MRI MRI ANGIOGRAPHY CT NUCLEAR MEDICINE I.V. Contrast I.V. Contrast I.V. Contrast Brain Scan Whole Body Bone Scan Whole Body Bone Scan w/SPECT 3 Phase Bone Scan Limited Bone Scan Site: ___________________ Liver/Spleen Scan HIDA Scan HIDA Scan w/Ejection Fraction Meckel’s Diverticulum Bowel Study MUGA Scan Gastric Emptying Ceretec White Blood Cell Specify ________________ Pulmonary Perfusion Imaging Pulmonary Ventilation Imaging Renal Flow & Scan Renal Flow & Scan w/Lasix Renal Flow & Scan w/Captopril Thyroid-123| Uptake & Scan Parathyroid Sestamibi Scan SPECT Specify ________________ Testicular Scan Other WITH WITHOUT BUN ________ Date ________ CREAT ______ Date ________ GFR ________ Date ________ Head Brain Pituitary Sinuses Orbits IAC’s TMJ’s Other __________________ Neck Entire Neck Nasopharynx Parotid MR Angio Other __________________ Chest Brachial Plexus Specify ________________ Spine C-Spine T-Spine L-Spine Sacrum Whole Spine Other __________________ Abdomen/Pelvis Abdomen Specify ________________ MRCP Pelvis Specify ________________ Bony Pelvis Orthopedic Extremities Shoulder Biceps Elbow Wrist Hand Hip Femur Knee Calf or Tibia/Fibula Ankle Foot Other __________________ Other Specify ________________ WITH WITHOUT WITH & WITHOUT WITH WITHOUT BUN ________ Date ________ CREAT ______ Date ________ CREAT ______ Date ________ GFR ________ Date ________ Brain Orbits Temporal Bones/IAC Middle Ear Facial Bones Sinuses DTI □ Landmark □ □ Medtronic Neck Chest Abdomen Abdomen & Pelvis Liver/Pancreas protocol Pelvis Bony Pelvis CT Urogram Renal Mass Urolithiasis Study SPINE □ C-Sp □ T-Sp □ L-Sp □ Sacrum & Coccyx □ R □ L Extremity Specify _______________ 3D Reconstruction□ R □ L Specify _______________ Scanogram Other GFR ________ Date ________ Intracranial (Brain) Extracranial (Neck) Thoracic Aorta Renal Artery Abdomen (Abdominal Aorta/ SMA/Renal/Celiac Axis) Pelvis/Bilateral Lwr Extrem w/runoff MRV Brain X-RAYS Chest Abdomen/KUB Obstruction Series Cervical Spine Soft Tissue Lateral Neck Thoracic Lumbar Spine Sacrum & Coccyx Scoliosis Series Skull Facial Bones Orbits Sinuses Nasal Bone AC joints Bone Age □ □ □ R L B Ribs Clavicle □□ R □□ L □□ B Scapula □ R □ L □ B Shoulder □ R □ L □ B Humerus □ R □ L □ B Elbow □ R □ L □ B Forearm □ R □ L □ B R L B Wrist □ R □ L □ B Hand Finger _________________ □ R □ L □ B Hip Femur □□ R □□ L □□ B R L B Knee Leg Tib/Fib □□ R □□ L □□ B R L B Ankle □ R □ L □ B Foot Calcaneus □ R □ L □ B Toe ___________________ Weightbearing □ Y □ N Other BUN ________ Date ________ CT ANGIOGRAPHY BUN ________ Date ________ CREAT ______ Date ________ GFR ________ Date ________ CTA Head (Circle of Willis) CTA Neck CTA Chest (P.E. Study) CTA Thoracic Aorta CTA Abdominal Aorta CTA Lower Extremities CTA Upper Extremity CTA Abdomen Renal Artery Runoff study WOMEN’S IMAGING & BREAST IMAGING Digital Mammography Screening: Routine; Asymptomatic Diagnostic Bilateral: Lump, personal hx of breast ca Diagnostic Unilateral □ R □ L Ultrasound (indicate problem on diagram) Right Breast Pelvic MRI ULTRASOUND Carotid Doppler Thyroid Abdomen, complete limited Abdomen, □ Right Upper Quadrant BONE DENSITOMETRY □DEXA w/Forearm Vertebral fracture assessment FLUOROSCOPY Esophagram Swallowing Function Upper GI Small Bowel Series Barium Enema Double Contrast BE CT SCREENING STUDIES These studies may not be covered by insurance. Chest Low-Dose (Lung Screening) SPECIFIC REQUESTS Left Breast □ Liver □ Gallbladder □ Pancreas □ Spleen Hepatic Vessels Doppler Retroperitoneum, complete (Kidneys & Urinary Bladder) Retroperitoneum, limited □ Kidneys □ Aorta □ IVC Limited Pelvis Urinary Bladder Pelvic-transabdominal only Pelvic-transvaginal only Pelvic Combined (transabdominal/transvaginal) Obstetrical LMP: / / Testicular/Scrotal Testicular/Scrotal w/Doppler Venous Extremity Upr (ARM) Doppler □ R □ L □ B Venous Extremity Lwr (LEG) Doppler □ R □ L □ B Arterial Extremity Lower Arterial Extremity Upper □ R □ L □ B Popliteal Fossa □ R □ L Color Doppler if indicated ______________________ Diagnostic Body Part ______________________ Other
Related documents