ORDER FORM PatientFirst name(Required) Last name(Required) CellPhone(Required)Date(Required) MM slash DD slash YYYY Insurance: Insurance ID: Group Attorney Attorney PhoneFax Sex: Male Female Other S.S. Pre Auth Bill To: Self Insurance Attorney Other Write Other Oral Sedation Yes No DoctorDoctor Name PhoneFax Clinical Findings/DiagnosisSignatureDate MM slash DD slash YYYY Creatinine BUN Date of Blood Work: MM slash DD slash YYYY STAT: Yes No Allergic to Iodine: Yes No Claustrophobic: Yes No MUSCULOSKELETAL / X-RaySHOULDER L R HUMERUS L R ELBOW L R FOREARM L R WRIST L R HAND L R HIP L R FEMUR L R KNEE L R TIBIA/FIBULA L R ANKLE L R FOOT L R TMJ L R Spine C-Spine T-Spine L-Spine C-Spine Views T-Spine Views L-Spine Views MRI 74181 Abdomen w/o 74183 Abdomen w + w/o Contrast 70551 Brain w/o 70553 Brain w + w/o Contrast 70553 Brain w/ IAC 73721 Knee R L 73221 Shoulder R L 73718 Foot R L 73721 Ankle R L 73221 Wrist R L 72141 Cervical Spine w/o 72156 Cervical Spine w +w/o 72146 Thoracic Spine w/o 72157 Thoracic Spine w + w/o 72148 Lumbar Spine w/o 72158 Lumbar Spine w + w/o 72195 Pelvis w/o 72197 Pelvis w + w/o 73721 SI Joints w/o 73723 SI Joints w + w/o 73721 Hip w/o R L 73723 Hip w + w/o R L CT 74150 Abdomen w/o 74170 Abdomen w+w/o Contrast 71250 Chest w/o 71270 Chest w + w/o Contrast 72192 Pelvis w/o 72194 Pelvis w + w/o Contrast 70450 Brain w/o 70470 Brain w + w/o Contrast 70488 Sinus (Specify Protocol) 70490 Soft Tissue Neck w/o 70492 Soft Tissue Neck w+w/o Con 70480 Temporal Bones w/o 72125 Cervical Spin w/o 72128 Thoracic Spine w/o 72131 Lumbar w/o BRAIN/BODY Brain MRA Head MRA Neck Paranasal Sinuses Sella/Pituitary Orbits Neck (Soft Tissue) MRA 74185 Abdomen w + w/o Contrast 70544 Head w/o 70547 Neck w/o OTHERS X-Ray X-Ray X-Ray Ultrasound Arthrogram – Shoulder R L Arthrogram – Knee R L Arthrogram – Other R L Arthrogram – Lumbar R L Arthrogram – Cervical R L ESI MRI PATIENTSNo Metal Prosthesis * No Pacemakers* No Aneurysm Clips * No Inner Ear Implant * No Dorsal Column/Stimulators No Metal Fragments in eyesDate MM slash DD slash YYYY Time Hours : Minutes AM PM NotesCommentsSpecial Instruction
