Oakland MRI & Diagnostics



Oakland MRI & Diagnostics

259 North Fourth Street

Oakland, Maryland 21550

Phone: 301-533-4674 Fax: 301-533-1077

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"Health Care with a Personal Touch"

Mammography Request Order Form

|Patient Name |Patient Phone |Date of Birth |

| | | |

|Ordering Physician Printed Name |Ordering Physician Signature |Ordering Date |

SCREENING MAMMOGRAM +

CAD:Bilateral (CPT – G 0202)

SCREENING MAMMOGRAM + TOMO:Bilateral (CPT-77063)

BREAST PROCEDURES:

DIAGNOSTIC MAMMOGRAM + CAD:

← Bilateral (CPT – G 0204)

← Unilateral Right (CPT – G 0206)

← Unilateral Left (CPT – G 0206)

DIAGNOSTIC

MAMMOGRAM + TOMO

← Needle localization

← Ultrasound if needed

← Extra views if needed.

DIAGNOSIS CODE: _____________________________________________________

COMMENTS: __________________________________________________________

________________________________________________________________________

PATIENT HISTORY:

← Routine

← Hormone Replacement Therapy

← Difficult Exam, bilateral dense breasts

← Augmentation/Implants, no symptoms

← History of Breast Reduction

← Biopsy proven benign breast disease, asymptomatic

← History of breast cancer; mother, sister, daughter

← Personal history of breast cancer, asymptomatic

← Did not give birth before age 30

← Other history or risk factors / Specify: ________________________________

Please bring this order form, a picture ID and your health insurance card with you to you appointment.

MRI Order/Dexa Order Sheet

Consent for Diagnostic Testing

(To Schedule Call: 301-533-4674 or 1-866-533-0674)

Patient’s Name: ______________________________

D.O.B________________ Weight: __________(Scanner not able to accommodate >350 bs)

Check which exam being ordered:

DEXA Exam: Reason for Exam:

(Make sure the patient does not receive IV contrast or Nu. Med.test 7 days prior to exam.)

MRI Exam Ordered: Reason for Exam:

Screening Indications for MRI (Circle Yes or No):**Please have Patient initial that

they answered questions correctly** _________

Pacemaker Yes/No Cerebral Aneurysm Clips Yes/No

EVER had/have Metal in the Eye* Yes/No Shrapnel Yes/No

EVER welded/ Grinded/Metal * Yes/No Heart Valve stents Yes/No

Cochlear Implant Yes/No Vena Cava Filter or Shunt Yes/No

Joint Replacement, Prosthesis, Rods Yes/No Electrodes, Neurostimulator Yes/No

Are You Claustrophobic ** Yes/No Will Sedation be Required?** Yes/No

History of Renal/Liver Failure?* Yes/No ** If “Yes”, Patient must obtain prescription

*If yes, Order BUN, Creatinine, or eGFR from Physician and have filled prior to

This form will serve as an order. exam. Patient must ALSO HAVE A

DRIVER!!

*If “Yes,” orbits must be ordered and cleared by the radiologist before the MRI exam can be done. If “Yes,” This form will serve as an order for the orbit x-ray exam.

Ordering Physician: _______________________________ M. D. Date:

Gadolinium

The radiologist may deem it necessary to give you an IV injection of a contrast liquid containing Gadolinium to improve the quality of your MRI exam. Although gadolinium contrast agents have been used safely in millions of patients, minor reactions (principally headache or nausea) occur in 2% of patients. Serious or life-threatening reactions have been reported in 1 in 400,000 patients. Therefore, please inform the technologist if you are:

▪ Pregnant

▪ Have any blood disorders that affect red blood cells

▪ Have a history of renal or hepatic disease, seizures, asthma or respiratory disorders.

▪

259 N. 4th. St. , Oakland, MD 21550 Office-301-533-4674, Fax-301533-1077

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