Women's Imaging Orders - Emory Johns Creek Hospital

ATTENTION PATIENTS:
Women’s Imaging Orders
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 __________________________ DOB: __________________ Patient Contact Number: _________________________________________
Diagnosis: ____________________________________________________ Precert needed: Yes No
ICD-9 Code: ___________________________________________________ Precert #:_____________________________________________________
Ordering Physician: _____________________________________________ 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.
Digital Mammography
Screening Mammogram (No Physician’s Order Required)
Diagnostic Mammogram
Diagnostic Mammogram
Reasons for Diagnostic Mammogram:
Breast Mass
Breast Pain
Symptoms of Pain or Rupture of Implants
Location of Lump or Pain (clock position):___________
Prior Abnormal Mammogram
Breast Cyst or Abscess
Retraction / Inversion of Nipple
Breast Lesion
Nipple Discharge
Mammary Dysplasia
Diagnostic Breast Studies
Diag. Bilateral Mammogram
(w/ Ultrasound if indicated)
Diag. Unilateral Mammogram [ Left or Right ]
(w/ Ultrasound if indicated)
Breast Ultrasound [ Left or Right ]
Stereotactic Breast Biopsy [ Left or Right ]
Ultrasound Core Biopsy [ Left or Right ]
Cyst Aspiration w/ Ultrasound Guidance [ Left or Right ]
Abnormal Screening Mammogram
(w/biopsy if indicated)
Call Patient to Schedule
Bone Density Services
Bone Density (DEXA) Whole Body
Reasons for DEXA Scan:
Osteoporosis
Osteopenia
Family History of Osteoporosis
Hormone Replacement Therapy
Post Menopausal
Recent Fracture
Other:______________________________________
MRI
Non-contrast Breast MRI for Implant Evaluation
Pre & Post Contrast MRI for Breast Cancer
Detection/Staging
With Sedation
OB Ultrasound
< 12 weeks
Multiple gestation < 12 weeks
13 – 16 weeks OB limited
Multiple gestation 13 – 16 weeks OB limited
Fetal detail 18 weeks and beyond
Multiple gestation 18 weeks and beyond
BPP (biophysical profi le)
BPP (biophysical profi le) – including growth parameter
Follow-up growth, fl uid, limited anatomy
Multiple gestation follow-up growth, fl uid, limited anatomy
Pelvic (NON OB) Ultrasound
Pelvic Complete (NON OB)
Pelvic Limited (NON OB)
Transabdominal (TA)
Transvaginal (TV)
Other Ultrasound Studies
Thyroid
Abdomen (complete)
Abdomen (limited-one organ; i.e., gallbladder)
Renal
Venous Doppler/lower ext-unilateral
Venous Doppler/lower ext-bilateral
Physician Office should obtain precerts for exams scheduled less than 24 hours in advance.
CALL TO SCHEDULE: 678-474-8100 FAX ORDERS TO: 678-474-8101
INSTRUCTIONS FOR PATIENT PREP ON REVERSE
Physician Signature: _____________________________________________________ Date: _______________ Time: _______________
Patient Information/Label
WOMENS IMAGING ORDERS
*IMG* 0340200953 rev 2/11
FORM CONTINUED ON BACK
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PREP INSTRUCTIONS FOR ADULT PATIENTS
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.
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.
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 fi ll 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 fi nancial 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 Hospital Parkway.
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 Hospital Parkway. Hospital is less than a
quarter mile on the right.
Address: 6325 Hospital Parkway, Johns Creek, GA 30097
Directions: 678-474-7090
Patient Information/Label
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