Referral Form - North Houston X-Ray and Imaging Center

 Phone: (713) 692-1133

411 W. Parker Rd., Suite A Houston, Texas 77091

northhoustonxray@ Fax: (713) 692-2299

Patient Name _________________________________________ D/O/B ______________________________________ Diagnosis ____________________________________________ Patient Phone # _______________________________

Without Contrast W & W/O Contrast

With Contrast MRI

SPINE/NEURO Brain Brain w/IAC Brain w/Pituitary Brain w/Sinuses Orbits TMJ Chest/Thorax Soft Tissue Neck Cervical Spine Thoracic Spine Lumbar Spine

UPPER EXTREMITY

Shoulder

L

R

Scapula

L

R

Humerus

L R

Elbow

L R

Forearm

L R

Wrist Hand

L R L R

LOWER EXTREMITY

Ankle Femur Foot

L R L R L R

Hip

L R

Knee

L R

Tib/Fib

L R

Pelvis

Abdomen MRCP Other

MRA

Abdomen/Renal Head/Circle Of Willis w/o Carotid/Neck w/o

Without Contrast

W & W/O Contrast

X With Contrast

CT

Abdomen

Abdomen & Pelvis

Pelvis

Head/Brain Orbit/Ear/Fossa Sinus/Maxillofacial Chest Soft Tissue Neck Cervical Spine

Thoracic Spine Lumbar Spine UPPER EXTREMITY

Shoulder

L

R

Humerus

L

R

Elbow

L

R

Forearm

L

R

Wrist

L

R

Hand

L

R

LOWER EXTREMITY

Hip

L

R

Femur

L

R

Knee

L

R

Tib/Fib ( Leg) L

R

Ankle

L

R

Foot

L

R

Other

CT ANGIOGRAPHY

Angio Abdomen Angio Abdomen Aorta Angio Abdomen & Pelvis Angiography Head Angiograph Chest Angiograph Neck

Angio Pelvis Angio Lower Extremity Angio Upper Extremity Other

Other

X-RAY

(All X-Rays are Routine Views, Unless Noted )

EXTREMITIES

Ankle

L

R

Elbow

L

R

Femur

L

R

Finger

L

R

Foot

L

R

Forearm L

R

Hand

L

R

Hip

L

R

Humerus L

R

Knee

L

R

Heel (Os Calcis) L R

Leg (Tib/Fib) L R

Toe(s)

L

R

Wrist

L

R

HEAD

Facial Bones

Mandible

Mastoids Nasal Bones

Orbits

Sellaturcica

Sinus Paranasal

Skull

TM Joints

Zygomatic Arches

ULTRASOUND

Abdomen

Gallbladder Kidney/Renal

Liver OB -Complete Pelvic Transabdominal Pelvic Transvaginal

Thyroid Prostate Transabdominal Testicular/Scrotum Soft Tissue (Mass) Soft Tissue (Extremity)

Other

ABDOMEN & PELVIS

Abdomen KUB

Abdomen Supine & Erect

Pelvis

CHEST

Chest (PA)

Chest (PA & LAT)

Lordotic View

Ribs

L

R

Sternum Sternoclavicular Joints

SHOULDER REGION

Clavicle

L

R

Scapula

L

R

Shoulder

L

R

Shoulder AC Joints L R

SPINE & PELVIS

Cervical Spine

Thoracic Spine Lumbar Spine

Sacrum & Coccyx

SI Joints

Scoliosis Thoracolumbar

Soft Tissue for Neck

Other

CARDIAC/VASCULAR

Echocardiogram (M.Mode,2DColorDoppler)

Carotid Doppler Venous Doppler Upper Ext. Venous Doppler Lower Ext. Arterial Doppler Upper Ext. Arterial Doppler Lower Ext.

Other

*FOR CONTRAST PATIENTS BUN:

CREATINE:

Date of Blood work

Physician Name

Physician Signature

Phone:

Date

Fax:

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