Shady Grove Radiology Appointment Form
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2SCHEDULING (301) 590-8999
Appointment Information
Date:_____________________________
Time:_____________________________
Patient Name: _________________________________________________________________________
Location:__________________________
Clinical History or Symptoms:_________________________________________________________________________________________
_________________________________________________________________________________________________________________
YOU MUST BRING
THIS PRESCRIPTION WITH YOU
Special Request:____________________________________________________________________________________________________
TO YOUR EXAM
Pre-Authorization #: ________________________________________________________ ICD9 Code:______________________________
See reverse side for patients requiring labs. **
Physician Name/Signature: __________________________________________________ Date: ___________________________________
**
BUN_____ CREATININE_____
STAT RESULTS
__________________________________
DATE DRAWN:______________
PT. TO BRING CD
HARD COPY IMAGES
DIAGNOSTIC X-RAY
FLUOROSCOPY
MRI
CT
MRA
No Appointment needed
IV Gadolinium **
Without Contrast
IV Contrast **
MRI Arthrogram
Chest
PA/LAT
PA only
Contrast per Radiologist
Contrast per Radiologist
Without/With Contrast
Joint: _________________
Abdomen
Circle of Willis/Brain
Contrast per Radiologist
______________________
Supine
Flat/Erect
Head
Neck/Carotid
Brain
Ribs
RT______ LT_______
CT IVP
Neck
Renal
Cervical Spine
ST Neck - Without/With Contrast
Sinuses
MRV Brain - Pre/Post Contrast
T-Spine
*Other Fluoroscopy procedures
Orbits
Screening
Other_______________
L/S-Spine
performed at Shady Grove
TMJ's
Complete
2D Reconstruction
Pelvis
Adventist Hospital.
NUCLEAR MEDICINE
Sella Turcica/Pituitary
Temporal Bones
Sacrum/Coccyx
Abdomen
- Without/With Contrast
Denta Scan
Lung VQ Scan
Hip
RT______ LT_______
MRCP - To Include Abdomen
RT______ LT_______
Chest
Brain Scan
Shoulder
ULTRASOUND
Pelvis
RT______ LT_______
Humerus
Abdomen
Bone Scan
C-Spine
RT______ LT_______
Elbow
OB
___1st___ 2nd___ 3rd Trimester
Pelvis
SPECT Bone Scan
T-Spine
RT______ LT_______
Forearm
Bio-Physical Profile
Renal Stone Study
Three Phase Bone Scan
L-Spine
RT______ LT_______
Wrist
Pelvic - Transabdominal
Thyroid Workup
Other__________________
Sacrum/Coccyx
RT______ LT_______
Hand
Transvaginal
I123 Uptake /Scan
as indicated
Shoulder
RT______ LT_______
RT______ LT_______
Finger
CTA
Resting Muga
Transvaginal
Elbow
RT______ LT_______
RT______ LT_______
Femur
Wrist
Hida Scan
IV Contrast required **
RT______ LT_______
Abdominal
RT______ LT_______
Knee
Hip
Gastric Emptying
RT______ LT_______
RT______ LT_______
Lower Leg
RUQ Abdominal
Head-Circle of Willis
Knee
RT______ LT_______
RT______ LT_______
Parathyroid Scan
Ankle
Renal
Neck (Carotids)
RT______ LT_______
Ankle
RT______ LT_______
Foot
Octreotide Scan
Pulmonary Embolism Study
Thyroid
RT______ LT_______
Foot
RT______ LT_______
Toe
Renal
Thoracic Aorta
Testicular
Doppler
as indicated
Other________________
Other__________________
WBC - Indium III
Abdominal Aorta
Carotid Doppler
Breast
Infection Scan
Renal Arteries
DIGITAL MAMMOGRAPHY
Venous Doppler of___________
(3D Recon. CAD)
RBC Liver Hemangioma
Lower Extremity
Arterial Doppler of___________
Implant Evaluation
Screening/CAD asymptomatic
Other:_____________
Other__________________
MRI Guided Biopsy
Hysterosonogram-Saline Infusion
Diagnostic/CAD symptomatic
Mammography clip placement as
HEALTH SCREENING
Breast sono as indicated
Menopausal YES_____ NO____
OTHER REQUEST
indicated for proper diagnosis
Breast
Right Breast ____Left Breast ____
Cardiac Scoring *
_____________________________
DXA
Ultrasound Guided Biopsy
Mammography Films Required
Screening Chest CT *
_____________________________
Mammography clip placement as
(if not done at SGR)
Bone Density Scan
indicated for proper diagnosis
_____________________________
* May not be covered by insurance
Other:__________________
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