Geisel School of Medicine at Dartmouth



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ED Radiology Request

REQUESTING PHYSICIAN: _________________________________ Pager #: ______________________

CLINICAL INDICATION:

Requested Date of Ultrasound:

PATIENT CONTACT PHONE/CELL#:

Requested Exam (please check): e-DH #

Tranvaginal Pelvic _____ IMG3514

Transvaginal Pelvic with Doppler______ IMG3514

Transabdominal Pelvic (full bladder required) ______ IMG1707

RUQ exam ______ IMG1220

Appendix ______ IMG1220

Intussception _____ IMG1220

Renal & Bladder ______ IMG3517

Scrotal _______ IMG3503

Other (please describe)___________________________________

**All abdominal exams need to be NPO for a minimum of 6 hours**

PHYSICIAN TO BE CONTACTED WITH ABNORMAL RESULTS:

(Day ultrasound is to be done)

NAME:______________________________________________________

PHONE:_____________________________________________________

PAGER:_____________________________________________________

SCHEDULING USE ONLY

**Patient has been sent home, non-emergent. Please contact patient at above number to arrange appointment. The patient should expect a phone from Radiology between 8-10 am

Date/ Time patient contacted: __________________________________________________________

Date/ Time exam scheduled:____________________________________________________________________

Unsuccessful contacting patient, # of attempts made:__________________

Phone call placed by: ____________________________________________

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PATIENT NAME:

MRN #:

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