Summit Medical Center — Casper – Elevating the Standards ...



FORMCHECKBOX STAT FORMCHECKBOX Call or FORMCHECKBOX Fax Results: #Summit Medical Center Diagnostic Imaging Order FormScheduling (307) 232-4070 Fax: (307) 215-0753Patient InformationName: Birthdate: Address: Phone: Insurance: 2nd Ins:Insurance ID: ID:Group #: Group#:***REQUIRED***Signs and Symptoms: ICD-10 Codes: ORDERING PHYSICIAN:Physician’s Signature: Date:X-RAY FORMCHECKBOX Chest O 1V or O 2V FORMCHECKBOX Ribs FORMCHECKBOX Abdomen O 1V KUB or O 2V FORMCHECKBOX Acute Abdominal Series 3V (incl. CXR) FORMCHECKBOX Soft Tissue Neck FORMCHECKBOX Clavicle O RT or O LT FORMCHECKBOX AC Joints FORMCHECKBOX C-Spine O 2V-3V O 4V-5V O Flex/Ext FORMCHECKBOX T-Spine O 2V O 3V O 4V FORMCHECKBOX L-Spine O 2V-3V O 4V-5V O Flex/Ext FORMCHECKBOX Pelvis FORMCHECKBOX Hip O RT or O LT FORMCHECKBOX Sacrum/Coccyx FORMCHECKBOX Upper Extremity O RT or O LTSpecify________________________ FORMCHECKBOX Lower Extremity O RT or O LTSpecify________________________ FORMCHECKBOX O Sinus O Facial Bones O NasalO Skull O Orbits FORMCHECKBOX Skeletal Survey FORMCHECKBOX Bone Age FORMCHECKBOX OTHER_______________________***No SCOLIOSIS Series*** MAMMOGRAPHY/BREAST FORMCHECKBOX Screening Mammo IMPLANTS ○ Y or ○ N FORMCHECKBOX Diagnostic Mammo FORMCHECKBOX Breast US FORMCHECKBOX Breast US If Indicated O RT O LT OR O Bilat (ORDER BILAT IF NO PRIOR MAMMO w/in 1 YEAR) O RT O LT OR O Bilat O RT O LT OR O BilatULTRASOUND FORMCHECKBOX Abdomen complete FORMCHECKBOX Abdomen limitedSpecify Organ:_______________________ FORMCHECKBOX GB O W/CCK FORMCHECKBOX Renal ○ Routine ○ W/Pre and Post Void FORMCHECKBOX OTHER____________________________ FORMCHECKBOX Aorta FORMCHECKBOX Hernia O RT or O LT FORMCHECKBOX Neck, Thyroid FORMCHECKBOX Carotid FORMCHECKBOX Extremity Non-Vascular FORMCHECKBOX Testicular FORMCHECKBOX Venous Doppler for DVT Lower Ext O RT or O LT Upper Ext O RT or O LT FORMCHECKBOX OB O Less than 14 weeks O Greater than14 weeks O Complete O (w/Add’l Gest) O Limited O Transvaginal O Follow up O Biophysical Profile O Umbilical Artery Doppler FORMCHECKBOX Complete Pelvic (transvaginal & transabdominal) FORMCHECKBOX Palpable Lump -Specify Site:_______________________ CT FORMCHECKBOX Perform BUN & Creatinine if needed. FORMCHECKBOX BUN & Creatinine performed within 30 days. Will send labsO WO IV ContrastO W IV ContrastO WO/W IV ContrastO Oral Contrast (Abd. and/or pelvis only) FORMCHECKBOX Abdomen FORMCHECKBOX Abdomen & Pelvis FORMCHECKBOX Stone Protocol (Abd/Pelvis No Contrast) FORMCHECKBOX Chest (no cardiac) O Routine O PE O Nodule FORMCHECKBOX Low Dose Lung Screening FORMCHECKBOX Head FORMCHECKBOX Sinus O Routine or O Stealth FORMCHECKBOX Facial Bones FORMCHECKBOX Orbits FORMCHECKBOX Mandible FORMCHECKBOX Soft Tissue Neck FORMCHECKBOX Pelvis O Mass or O Bony FORMCHECKBOX Extremity Upper O RT or O LT Specify Part________________ FORMCHECKBOX Extremity Lower O RT or O LT Specify Part________________ FORMCHECKBOX CONFORMIS Knee O RT or O LT FORMCHECKBOX C-Spine FORMCHECKBOX T-Spine FORMCHECKBOX L-Spine FORMCHECKBOX CT AngiographySpecify Exam:_________________ FORMCHECKBOX OTHER____________________MRI FORMCHECKBOX IF NECESSARY, please perform X-RAY ORBITS, Foreign Body for MRI Screening FORMCHECKBOX Perform BUN & Creatinine if needed. FORMCHECKBOX BUN & Creatinine performed within 30 days. Will send labs.O WO IV ContrastO WO/W IV ContrastO Arthrogram FORMCHECKBOX Brain FORMCHECKBOX Pituitary FORMCHECKBOX IAC FORMCHECKBOX Orbits FORMCHECKBOX Soft Tissue Neck FORMCHECKBOX MRASpecify:________________ FORMCHECKBOX MRVSpecify:________________ FORMCHECKBOX Abdomen FORMCHECKBOX MRCP FORMCHECKBOX C-Spine FORMCHECKBOX T-Spine FORMCHECKBOX L-Spine FORMCHECKBOX Pelvis FORMCHECKBOX Pelvis Sports Hernia FORMCHECKBOX Female PelvisSpecify:__________________ FORMCHECKBOX Sacrum FORMCHECKBOX Extremity Upper O RT or O LT Specify Part:__________________________ FORMCHECKBOX Extremity Lower O RT or O LT Specify Part:__________________________ FORMCHECKBOX OTHER____________________________ ................
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