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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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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