Medical Diagnostic Imaging Franklin, Wisconsin | Premier ...
MDI-Franklin MDI-Greenfield MDI-Milwaukee
(MRI, US, CT & X-Ray) (MRI & US) (MRI, US, CT, X-Ray & Fluoro)
3111 W Rawson Ave Ste #105 6150 W Layton Ave 8522 W Capitol Dr
Fax: (414) 301-4501 Fax: (414) 282-4105 Fax: (414) 847-1820
Phone: 414-282-4100
|PATIENT INFORMATION |
|Patient Name (Last): | |(First): | |DOB: | M F |
|Address: | |Phone: | |Cell Phone: | |
|City: | |State: | |Zip: | |
| |Allergies/other risk factors | |
| |Claustrophobic (If sedation is requested, a driver is required to and from exam) |
|INSURANCE/AUTHORIZATION INFORMATION (Please fax front and back of all insurance cards) |
| |Commercial |ID/Group #: | | Medicare | Medicaid |
|Authorization to be obtained by: | MDI | Referring Provider |Auth #: |Exp: |
|TYPE OF EXAM |
|DIAGNOSIS/ICD-10 Code (REQUIRED) |
|Radiography/ |Radiography of: | | Left Right |
|X-ray | | | |
| | | | |
|FR & MILW | | | |
| | Chest X-ray 2 view | | Scoliosis 2 view | Spine: |
| | |Abdomen X-ray: | | |
| | | | |Cervical Thoracic Lumbar |
| | |AP view 2 view | | |
| |Other or special request: |
|Fluoroscopy/ | UGI | Small Bowel | Colon | VCUG | Esophagram | OPMS |
|Interventional | | | | | | |
| | | | | | | |
|MILW | | | | | | |
| | Arthrogram: | | | LP | Aspiration/Biopsy | Steroid Injection |
| | | |CT | | | |
| | | | | | | |
| | | |MRI | | | |
| |Other or special request: |
|MRI | Chest | Abdomen | Pelvis | Chest | |
| | | | | |Spine: |
|Contrast | | | | | |
| | | | | |Cervical Thoracic Lumbar |
|No Contrast | | | | | |
| | | | | | |
|GR, FR & MILW | | | | | |
| | MRA of: | | Head/Brain | Orbits | IAC/Posterior Fossa | Soft Tissue Neck |
| | Extremity: | | | Knee: | Shoulder: |
| | | |Hip: | | |
| | | | |Left Right |Left Right |
| | | |Left Right | | |
| |Other or special request: |
|CT | Head | Temporal Bones | Sinus | Abd/Pelvis |
| | | | | |
|Contrast | | | | |
| | | | | |
|No Contrast | | | | |
| | | | | |
|FR & MILW | | | | |
| | CTA: | | Extremity: | | Left Right |
| |Other or special request: | |
| |Creatinine Level: | mg/dL |Date Performed: | |(OPTION: Creatinine draw can be done at MDI) |
|Ultrasound | Carotid | Vascular screening/ABI | Abdomen | Pelvis | Transvaginal |
| | | | | | |
|FR & MILW | | | | | |
| | Renal | Extremity Arteries | Extremity Veins | Thyroid | Scrotum |
| | Pylorus | Infant Hips (< 6mos) | Infant Spine | | |
| |Other or special request: | |
|PHYSICIAN INFORMATION |
|Physician Phone: |Physician Fax: | SEND CD WITH PATIENT | STAT RESULTS |
| | | |
|X_______________________________ PHYSICIAN’S SIGNATURE (REQUIRED) |PLEASE PRINT PHYSICIAN NAME |DATE |
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