Outpatient Imaging Order Form - Medical City Dallas Hospital
Outpatient Imaging Order Form - Medical City Dallas Hospital
Outpatient Imaging Order Form - Medical City Dallas Hospital
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Scheduling: 972-612-6525 Fax: 469-484-2326<br />
# Pages Faxed for this order<br />
Comments/Other Procedures<br />
To request radiology images or reports contact us at 972-566-7226<br />
MRI<br />
with Sedation<br />
CT<br />
W/O Contrast<br />
Long Leg Runoff Femoral Arteries Aorta-Thoracic<br />
Aorta-Abdominal<br />
Renal Arteries<br />
Dural Sinuses/ Veins (head)<br />
Portal Vein-Inferior Vena Cava<br />
Intracranial/Arteries (head) Extracranial/Arteries (neck)<br />
Nuclear Medicine<br />
with Sedation<br />
Bone Scan<br />
Total Body<br />
Limited<br />
3 Phase<br />
SPECT<br />
Lung Scan<br />
V/Q<br />
RenalScan<br />
Lasix<br />
DMSA<br />
Quantification<br />
Differential Function<br />
Captoptil<br />
Call Pt to<br />
Schedule<br />
Date of Scheduled<br />
Exam:<br />
Add-On Today<br />
Authorized by:<br />
Patient Name DOB Circle One: Male Female Pt, Weight<br />
Pt Phone Numbers or Address<br />
Insurance Name Verification Phone<br />
Authorization #<br />
Group Plan # Pt Ins Id #<br />
SS #<br />
Test/Procedure<br />
Diagnosis<br />
(All test/procedures ordered must have a diagnosis and reason for testing)<br />
<strong>Order</strong>ing Physician (please print)<br />
Physician's Signature (required for order)<br />
RIGHT<br />
Hand<br />
Knee<br />
Hip<br />
with Sedation<br />
W & W/O Contrast W/Oral Contrast W/Contrast W/O Contrast W & W/O Contrast<br />
Brain<br />
Brain w/lAC's<br />
IAC's<br />
Brain<br />
Sinuses<br />
Chest<br />
C-Spine T-Spine<br />
L-Spine<br />
Temporal Bones (IAC's)<br />
Maxillofacial w/coronals<br />
TMJ<br />
Neck (soft tissue)<br />
Orbits<br />
C-Spine T-Spine L-Spine Extremity<br />
Pituitary<br />
Cardiac<br />
Chest<br />
Pelvis (soft tissue)<br />
MRCP<br />
Sacrum & Coccyx<br />
Liver<br />
Abdomen<br />
Neck Soft Tissue<br />
Abdomen (only)<br />
Kidney Stone<br />
CT - Angio<br />
Abdomen/Pelvis<br />
Pancreas/Thin Cuts<br />
LEFT<br />
RIGHT<br />
BILATERAL<br />
US<br />
Breast<br />
Forearm<br />
Elbow<br />
Shoulder<br />
Pelvis<br />
Wrist<br />
Humerus<br />
Hip<br />
Knee<br />
Femur<br />
Ankle<br />
Tibia/Fibula<br />
Hand<br />
Foot<br />
Abdomen<br />
Abdomen Limited<br />
Abdominal Aorta<br />
Transvaginal<br />
Bladder<br />
Complete OB<br />
MRA/MRV with Sedation Gallbladder<br />
Soft Tissue Neck<br />
Fluoroscopy<br />
VCUG<br />
Liver/Spleen Scan<br />
RBC Lvr Hemangioma<br />
Cardiac MUGA Scan<br />
Meckels Scan<br />
Gastric Emptying<br />
Gallium Scan<br />
White Blood Cell<br />
I-123 MIBG<br />
Hepatobiliary (HIDA)<br />
with CCK<br />
Myocardial Perfusion<br />
Hepatobiliary (HIDA)<br />
Stress/Rest 2 Day Protocol w/o CCK<br />
Thyroid Uptake/Scan – I-123 Lymph/ Sentinel<br />
6 hr 24 hr Prostascint<br />
Parathyroid Octreotide Zevlan<br />
I-131 Whole Body Scan<br />
Brain SPECT<br />
Therapy I-13130mCi<br />
Ablation I-13130mCi<br />
Phone<br />
Barium Burger<br />
Esophagram<br />
Cystogram<br />
Arthrogram:<br />
VCUG<br />
Lumbar Puncture<br />
Myslogram: Cervical<br />
Modified Barium Swallow<br />
Upper GI<br />
Barium Enema w/Air Contrast<br />
VCUG w/Gas Sedation<br />
Defacography<br />
Myelogram: Thoracic<br />
Skull<br />
A&P/Lat Cephs<br />
Neuro Skull Facial Bones<br />
Panorex Orbits<br />
Mandible Sinuses<br />
TMJ<br />
NasalBones<br />
Mastoids Neck – Soft Tissues<br />
ABDOMEN<br />
Flat & Upright<br />
Bone Survey<br />
Abdomen Series<br />
2 View<br />
Shoulder<br />
Humerus<br />
Tibia/Fibula<br />
3 View<br />
Clavicle<br />
Forearm<br />
Femur<br />
Pelvis<br />
SI Joints<br />
KUB<br />
Radiology<br />
LEFT<br />
Elbow<br />
Wrist<br />
Ankle<br />
Fax<br />
Date<br />
STAT<br />
Facial Bones<br />
Orbits<br />
3-D Reformation<br />
Pelvis (Only)<br />
Renal/Adrenals<br />
Pelvis<br />
Kidney<br />
Thyroid<br />
Testicular<br />
Small Bowel<br />
Barium Enema<br />
HSG<br />
VCUG w/VERSED<br />
IVP<br />
Myelogram: Lumbar<br />
HEAD SPINE CHEST<br />
AP & Lateral<br />
3 views<br />
5 views<br />
Flex/ Extension<br />
Cervical<br />
Thoracic<br />
Lumbar<br />
Sacrum & Coccyx<br />
Scoliosis Study<br />
Rapidscreen<br />
Chest CAD will be<br />
completed on all<br />
chest x-rays. We<br />
will follow<br />
protocols for age<br />
and timeliness.<br />
PA & Lateral<br />
PA or AP Only<br />
Sternum<br />
Ribs – Left<br />
Ribs – Right<br />
BILATERAL<br />
Finger<br />
Foot<br />
Toe Bone Age<br />
Pregnancy Test<br />
(Blood Serum)<br />
Electrocardiogram<br />
(EKG)<br />
7777 Forest Lane • <strong>Dallas</strong>, Texas 75230 • (972) 566-7000<br />
IMAGING ORDER FORM<br />
*POS*<br />
MCD02008 (Rev. 11/12) Page 1 of 2
Patient Name DOB Circle One: Male Female Pt Weight<br />
Pt Phone Numbers or Address<br />
Insurance Name<br />
Group Plan #<br />
Test/Procedure<br />
Pt Ins Id #<br />
Diagnosis<br />
(All test/procedures ordered must have a diagnosis code and reason for testing)<br />
Verification Phone<br />
SS#<br />
CPT Code<br />
<strong>Order</strong>ing Physician (please print)<br />
Phone<br />
Fax<br />
Physician's Signature (required for order)<br />
Date<br />
Comments/Other Procedures<br />
Vascular/Interventional - For these exams contact 972-566-7866 (phone) or 972-566-6290 (fax)<br />
STAT<br />
Angiogram:<br />
Balloon Angio/Endovascular Stent<br />
Abscess Drainage/Abcessogram<br />
Biliary Drainage/Stent<br />
Uterine Fibroid Embolization<br />
Embolization<br />
Kyphoplasty<br />
Dialysis Fistula Thrombectomy<br />
IVC Filter Placement<br />
Nephrostomy/Nephostogram<br />
Other VASC/Interven<br />
Biopsy:<br />
Medi Port<br />
Central Line Placement<br />
Venous Sampling<br />
Venogram<br />
Myelograrn<br />
Kyphoplasty - For these exams contact 972-566-7866 (phone) or 972-566-6920 (fax)<br />
Thoracic Spine (Level ) Lumbar Spine (Level )<br />
Please check all signs and symptoms related to this patient (Kyphoplasty only)<br />
Closed thoracic fx w/o spinal cord injury (additional information needed regarding cause)<br />
Metastatic disease<br />
Closed lumbar fx w/o spinal cord injury (additional information needed regarding cause)<br />
Tumor<br />
Osteoporosis<br />
Compression fx (additional information needed regarding cause)<br />
Other<br />
Pathologic fx (additional information needed regarding cause)<br />
For More Information about Your Procedure visit us at:<br />
www.medicalcityimaging.com<br />
<strong>Medical</strong> <strong>City</strong> <strong>Imaging</strong> at<br />
<strong>Medical</strong> <strong>City</strong> <strong>Dallas</strong> <strong>Hospital</strong><br />
7777 Forest Lane<br />
Building D, Suite 200<br />
<strong>Dallas</strong>, Texas 75230<br />
DialysislApheresis Cath<br />
PICC<br />
Epidural Steroid Injection<br />
Paracentesis<br />
Thoracentesis<br />
PARKING: Parking access to Building D is located at the corner of Park Central<br />
and Merit Drive. Building D valet parking available from 8:00 a.m. to 5:00 p.m.<br />
Visitor Parking is open 24 hours a day at the corner of Forest Lane and Park<br />
Central Drive for Buildings A,B, and C. Parking fees are as follows:<br />
Up to 1 hour: $1.00 61 minutes - 2 hours: $2.00 Over 4 hours: $4.00<br />
Valet Parking for visitors is available Monday through Friday for $4.00 per<br />
day at Building A and C from 8:00 a.m.-6:00 p.m., and at Building D from<br />
8:00 a.m.-5:00 p.m.<br />
Parking Meters are also available on Park Central Drive.<br />
7777 Forest Lane • <strong>Dallas</strong>, Texas 75230 • (972) 566-7000<br />
IMAGING ORDER FORM<br />
*POS*<br />
MCD02008 (Rev. 11/12) Page 2 of 2
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