4511 North Davis hwy. Suite 1B P Pen MRI toll Free (866 ...

4511 North Davis Hwy. Suite 1B Pensacola, FL 32503

NPI# 1235197930 Tax ID: 59-3551727 Phone: 850.484.8454 ? Fax: 850.484.7754

Toll Free: 844.484.8454

Patient's name: Mobile #:

Alternate #:

DOB:

Call patient to schedule Fax order, front/back of insurance card and any clinical information

Please call to schedule STATs

Appointment date:

Abdomen Aorta Brain Cervical Spine Chest IAC's Lumbar Spine MRCP of Abdomen Orbits, Face & Neck

Arrival time:

am / pm Appointment Time:

am / pm Revised Order

HIGHFIELD MRI OPEN MRI

Pelvis Soft Tissue Neck Thoracic Spine TMJ Lower Extremity (Non-Joint) Lower Extremity (Joint)) Upper Extremity (Non-Joint)) Upper Extremity (Joint) Other:

2 Right 2 Left 2 Bilateral

MRA MRA Brain MRA Neck NRA Renals MRA Abdominal MRV

MRI CONTRAST Without With and Without At Radiologist's Discretion

Abdomen Abdomen/Pelvis Brain Cardiac Scoring Cervical Spine Chest HRCT Chest Limited Study Lower Extremity Lumbar Spine Neck, Soft Tissue Orbits Pelvis Sinus

CT

Sinus, Limited Thoracic Spine Urogram Upper Extremity Other:

CT CONTRAST With Without With and Without At Radiologist's Discretion

ULTRASOUND

Abdomen Aorta Appendix Arterial Doppler / Imag. upper Arterial Doppler / Imag. Lower Carotid Echo Echo Stress Extremity Non-Vascular Gallbladder Neonatal head

Pelvis / transvaginal OB 13 Wks or Less OB 14 Wks or More Renal / Bladder Renal Arterial w/Color Doppler Scrotum w/Color Doppler Thyroid Transplant w/Color Doppler Venous Doppler / Imag. upper Venous Doppler / Imag. Lower Other:

X-RAY

CHEST / THORAX Chest 2 View Chest 1 View Ribs 4 View Ribs Bilateral 5 View Sterno-Clavicular (SC) Joint Sternum

SPINES Cervical Spine Full 5 View Cervical Spine Limited 3 View thoracic Spine 3 View Lumbar Spine Full 5 View Lumbar SpineLimited 3 View Scoliosis Series (AP only)

SKULL Skull Series Sinus Series - 4 views Orbits Orbits - Metal Screening

ABDOMEN / PELVIS Abdomen 1 view (KuB) Abdomen Series Pelvis 1 view

Sacro-Iliac (SI) Joints Sacrum/Coccyx

UPPER EXT. Shoulder-3 view Humerus-2 view Elbow-3 view Forearm-2 view Wrist-3 view Hand-3 view Fingers-3 view

LOWER EXT. Hip-2 view Bilat. Hips-5 views Femur-2 view Knee-4 view Tib-Fib 2 view Ankle-3 view Foot-3 view Heel - 2 view Toes-3 view

Other:

Right Left

ROUTINE REPORT - 24-48 HOURS

*Please call to schedule all STATs

COMPARISON STUDIES

Location:

STAT Fax - report in 2 hours Fax

Call Report- Radiologist will call Backline/Cell

Insurance (Please fax front and back of patient's card and any clinical information to 850.484.7754) Date: Clinical indications/Signs/Symptoms:

ICD-10 Code(s): Provider name (printed):

Provider signature:

ALL IMAGES AVAILABLE TO DOCTORS THROUGH OUR SECURE ONLINE PACS

REV: 11.2020

PATIENT INSTRUCTIONS: PREPARING FOR YOUR EXAM BRING THIS ORDER WITH YOU TO YOUR SCHEDULED EXAM

MRI (MAGNETIC RESONANCE IMAGING)

Our office will contact you 24 hours before your appointment to confirm your appointment and provide prep instructions.

CT (COMPUTED TOMOGRAPHY)

Our office will contact you 24 hours before your appointment to confirm your appointment and provide prep instructions.

Do not wear eye makeup or mascara for ANY Brain & Neck studies. Do not wear any jewelry or hairpins. Wear comfortable clothing.

Let us know if you have: ? Metallic fragments in your eyes or previous injury to the

eye involving a metal object ? Any type of implanted mechanical pump ? Any type of surgery within the past 8 weeks ? A history of cancer ? A pacemaker/ defibrillator/ stimulator ? An aneurysm clip ? Any metallic/ electronic implant

Oral prep ? You may be given Readi-Cat, a Barium Sulfate suspension,

to drink for your CT Scan. ? This is not a laxative. Its purpose is to enhance your

digestive tract so that the radiologist can better visualize your anatomy during your CT Scan. ? If you have ever had any reaction to X-ray dye, please call us at 850.484.8454 prior to your exam.

ULTRASOUND

Our office will contact you 24 hours before your appointment to confirm your appointment and provide prep instructions.

Let us know if you are: ? Allergic to CT or MRI contrast ? Claustrophobic ? Pregnant/Nursing ? In need of special assistance

4511 North Davis Hwy, Suite 1B Pensacola, FL 32503 Scheduling: (850) 484-8454 Phone: (850) 484-8454 Fax: (850) 484-7754

DIRECTIONS: Located in the Gulf Coast Medical Arts Complex between Brent and Fairfield on Davis Highway. enter either of the two entrances and make a left. Park on the south side of complex. Follow the archways to MRI facility -- Suite 4511 B.

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