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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