Outpatient Imaging Orders - Emory Johns Creek Hospital

EmoryJohnsCreek.com
Outpatient Imaging Orders
ATTENTION PATIENTS: Please remember to bring this form with you to the hospital for your test. Your test may be delayed
or cancelled if we do not have this form.
Patient Name:
Diagnosis:
ICD-9 Code: Precert #:
Ordering Physician:
Patient Contact Number:
Precert needed: Yes No
Referral needed: Yes No
Physician Phone Number: STAT Call Report to: Yes No #:
Physician Signature and Date: NPI #:
ATTENTION PHYSICIAN OFFICES: Please select tests below.
CT SCANNING
With contrast (as specified by Radiologist MD)
Chest
Chest High Resolution (no contrast)
CT Chest (P.E.) / Dissection
Abdomen/Pelvis (diaphragm to pubis)
Abdomen (diaphragm to iliac crest)
Pelvis (iliac crest to pubis)
Head
Sinus (axial and coronal)
Orbitis
Temporal Bone
Neck
Cervical Spine
Thoracic Spine
Lumbar Spine
Facial Bones
Extremity
Specify:
CTA
Specify:
Other:
Cardiac Calcium Scoring
Lung Screening
Combo Exam: Lung Screening / Cardiac
Calcium Scoring
MRI
With contrast (as specified by Radiologist MD)
With sedation
Brain
MRA
Intracranial / Head
Extracranial / Neck
MRA ABD
MRA Runoff
MRV
Neck / Soft Tissue
TMJ
Brachial Plexus
Lumbar Plexus
Spine
Cervical
Thoracic
Lumbar
Chest
Abdomen
Pelvis
Extremities
Specify: R L
Non-contrast Breast MRI for Implant Evaluation
Pre & Post Contrast MRI for Breast Cancer
Detection/Staging
MRCP
X-RAY (Plain Films)
Chest – Single View (PA)
Chest – PA & Lateral
Ribs: R L
NUCLEAR MEDICINE
Abdomen – KUB
Abdomen – Flat, Upright & Chest
Skull
Bone Scan
Cisternogram
Gallium Scan
3 Phase
Sinuses
Facial Bones
Nasal Bones
Cervical Spine
With Flexion / Extension
Obliques
Thoracic Spine
Lumbar Spine
With Obliques
With Flexion / Extension
Sacrum / Coccyx
Pelvis
Gastric Emptying
GI Bleed Scan
Abdomen
Lung / VQ Scan
Hemangioma
Heptobiliary Scan
With CCK
Liver / Spleen Scan
Lymphoscintigraphy
Specify:
MUGA / Ejection Fraction
Parathyroid
Hip R L
Renal Scan
Femur R L
With Lasix
Knee R L
Shunt Patency Study
Lower Leg R L Thyroid (Tibia Scan / and Fibula) Uptake
Ankle R L
Thyroid Update Only
Foot R L
Thyroid Scan Only
Toes R L
Therapy for Hypothyroidism
Shoulder R L
Therapy for Thyroid
Humerus R L
Whole Body Survey (I-131)
Forearm R L
White Blood Cell Study
Elbow R L
Specify:
Wrist R L
Other:
Hand R L
Fingers R L
ULTRASOUND
Specify:
Abdominal
Metastatic Survey
Abdominal Limited
Other:
Myleogram
Cervical
Thoracic
Lumbar
Lumbar Puncture
Specify Details:
RUQ AORTA
FLUOROSCOPY
Esophagram
Hysterosalpingogram
UGI
UGI & Small Bowel Series
Small Bowel Series
Barium Enema
IVP
Cystogram
With Voiding Films
Retrograde Urethrogram
Arthrogram with MRI with CT
Specify:
Video Swallowing Study
Other:
Gallbladder Liver
Other:
Renal With Doppler
Renal Transplant
Pelvic with Transvaginal
(if needed)
Testicular
Carotid
Thyroid
Venous
Upper Lower
Right Left Bilateral
Arterial
Upper Lower ABI
Right Left Bilateral
Bladder
Paracentesis / Thoracentesis
Diagnostic
Therapeutic
Other:
Physician Office should obtain precerts for exams scheduled less than 24 hours in advance.
Call Patient to Schedule
INTERVENTIONAL
Port Placement
Double Lumen PICC Line Placement
VAS Cath
Perma Cath
Arteriogram
Radio Frequency Ablation (RFA)
Requires Consult
Specify:
Consults:
Women’s Imaging
Cancer Treatment
Fracture Treatment
Pain Management
Port Check - Stripping
Replacement, if needed
Abscess/ Fistula/ Sinus Tube Check
Drainage Tube Change – Any Type
Specify:
Dialysis Shunt Study/AV Fistulagram
Biliary Drainage
Cholangiogram
Myelogram / Discogram
Cervical Level:
Thoracic
Lumbar
Percutaneous Nephrostomy
R L Bilateral
Ureterostomy
R L Bilateral
Embolization – Requires Consult
Specify:
Lumbar Drain
IVC Filter Placement
Port Removal
Percutaneous Drain Placement
Specify:
Arthrogram
Specify:
UAE / UFE – Requires Consult
MUSCULOSKELETAL
Tendon Sheath Injection
Rt Ankle Lt Ankle
Vertebroplasty
Acetabuloplasty
Socroplasty
Kyphoplasty
Specify Level:
Consult Desired
Joint Injection
Specify:
Other:
Other:
Epidural Injection
Nerve Block
CALL TO SCHEDULE: 678-474-8100 FAX ORDERS TO: 678-474-8101
INSTRUCTIONS FOR PATIENT PREP ON REVERSE

PREP INSTRUCTIONS FOR ADULT PATIENTS
(Please call for instructions for pediatric patients)
BARIUM ENEMA WITH AIR CONTRAST:
BARIUM ENEMA AND/OR SMALL BOWEL SERIES:
(Follow LoSo Prep which can be picked up at the hospital)
MAMMOGRAM:
Wear 2-piece clothing. Do not wear any body powder, deodorant, cream or
lotion in the area of the breast or underarm. Bring previous mammograms
from other facilities.
ULTRASOUND – PELVIC OR OBSTETRICAL:
Female patients should drink 32 oz. of water one hour before the examination
and should not empty bladder. The bladder must be full for the examination.
ULTRASOUND – ABDOMEN (KIDNEY, LIVER, SPLEEN, AND AORTA,
PANCREAS, AND GALLBLADDER):
Do not eat or drink anything after midnight the night before your exam.
MYELOGRAM:
Drink plenty of water 24 hours before exam. NPO (nothing to eat or drink)
after midnight. Take any current medications. Please call Imaging Services if
you are taking aspirin or any blood thinning medications, for directions.
MRI:
Patients who have a PACEMAKER may NOT have an MRI performed. If a
patient has metal in their body, or if they are claustrophobic, you must contact
Imaging Services department prior to scheduling the exam.
CT:
You may not drive after being sedated for your test. Please make
arrangements to have someone drive you home after your procedure. Do not
eat or drink anything for 6 hours after your procedure.
If, for medical reasons, these instructions are not advisable, please call Imaging
Services for alternative preparation at 678-474-8071 or contact your physician.
‣ For studies requiring oral contrast, please stop by the Imaging Department to
pick up instructions and contrast.
‣ IV contrasted studies – NPO (nothing to eat or drink) 4 hours prior to exam
‣ All patients scheduled for invasive procedures will be contacted with
instructions.
Your Appointment Date:_______________________ Time:____________
Please bring this physician order form with you on the day of your
appointment. Your procedure cannot be performed without a written
order from your doctor. The start of your procedure may be delayed if we
need to call your physician for another order to be faxed.
In preparation for your tests:
Please follow any fasting or procedure preparation instructions before coming
for your tests.
To save time, please call 678-474-7084 to pre-register or visit our website,
EmoryJohnsCreek.com to print and fill out registration forms prior to your
arrival. Please remember to bring with you at the time of registration the
following items:
All active insurance cards
Picture ID
Physician orders
Patients are responsible for all financial liabilities including co-payments,
deductibles, and out-of-pocket expenses at the time of registration or at the
time of discharge for emergency admissions. If the exact dollar amount has
not been determined, you will be asked to pay the estimated amount and will
be billed for the remainder.
We invite you to use our complimentary valet parking when you arrive.
Directions
From I-85: Take Pleasant Hill Road
exit. Travel west on Pleasant Hill for
5 miles until it becomes State Bridge
Rd. Turn right onto Medlock Bridge
Road (GA 141 N/Peachtree Pkwy).
Go 3.5 miles and turn left onto West
Johns Crossing. Hospital is less than
half a mile on the left.
From 400: Exit 10 (GA 120/Old
Milton Pkwy) - Merge onto GA 120 E
towards Duluth. Turn left onto
Kimball Bridge (GA 120E). Turn left
onto Jones Bridge Rd. Turn right
onto Sargent Road. Sargent Rd.
becomes McGinnis Ferry Rd. Turn
right onto West Johns Crossing.
Hospital is less than a quarter mile on
the right.
Address: 6325 West Johns Crossing, Johns Creek, GA 30097
Directions: 678-474-7090