BAHAMAS FACILITY OLD RIVER FACILITY DOWNTOWN …...SAN DIMAS FACILITY 3838 San Dimas, #A-120...
Transcript of BAHAMAS FACILITY OLD RIVER FACILITY DOWNTOWN …...SAN DIMAS FACILITY 3838 San Dimas, #A-120...
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Clinical History/Reason for Exam:
Insurance Information: Patient’s Phone:
Referring Physician (please print): Physician Signature:
Phone:Patient to bring images to Doctor
Call in STAT resultsAfter hours contact#: ______________________________
CTMRI
With & Without ContrastWithout ContrastBrainNeuroquantSoft Tissue NeckOrbitsFaceSpine: __Cervical __Thoracic __Lumbar
Arthrogram (Direct)
Prostate
MR AngiographyHead-Circle of Willis (w/o Contrast) Neck (Carotids)Abdomen (Renals)Abdominal AortaThoracic AortaLower Extremities w/Runo�sOther: _________________________
Diagnostic CTWith Contrast
Without Contrast
SinusesBrain/Head
Facial Bones/Maxillo FacialTemporal Bones/Ear/OrbitSoft Tissue (Neck)Spine: __Cervical __Thoracic __LumbarPost Mylogram: __Cervical __Thoracic __LumbarLow Dose Lung (Chest) __Screening __Follow-upCalcium Scoring (w/o Contrast)
Cardiac MorphologyAbdomenPelvisEnterographyCT UrogramJoint: _____________ __Left __RightExtremity: ___________ __Left __RightBiopsy______________________
Other: _________________________
CTA (Angiography)Head (Circle of Willis)Neck (Cartorids)Abdominal AortaThoracic AortaCoronary CTATAVRAbdomen/PelvisLower Extremities Runo�s
ULTRASOUND
PET/CT
Abdomen CompleteRenal
X-RAY/FLUOROSCOPYChestAbdomen (KUB)SkullPelvisScoliosis SeriesSpine: __Cervical __Thoracic __LumbarHands: __Left __RightWrist: __Left __RightHip: __Left __RightKnee: __Left __RightAnkle: __Left __RightFoot: __Left __RightShoulder: __Left __RightLong Bone: ___________ __Left __RightEsophagramSmall Bowel Series/SBFTUpper GIBarium EnemaHysterosalpingogramVoiding CystourethrogramOther: _________________________
INTERVENTIONALConsultation
DEXABone Density Screening
Vertebroplasty/KyphoplastyLevel: _________________________DiscogramLevel: _________________________Myelogram: __Cervical __Thoracic __LumbarLumbar PunctureEpiduralLevel: _________________________PICC Placement: __Eval __ExchangeCentral Dialysis Cath:__Eval __Exchange __Insert __RemovePort-O-Cath: __Placement _RemovalThrombectomyAnatomy: ______________________Drain: __Placement __RemovalVenogramAnatomy: ______________________AngiogramAnatomy: ______________________FistulogramOther: _________________________
Renal/BladderABD LimitedProstateRenal TransplantThyroidSoft Neck TissueScrotum/TesticlesPelvic Transvaginal only (non-ob)Pelvis w/o Transvaginal Pelvis w/ TransvaginalOBTVS < 13 WeeksObstetrical CompleteObstetrical LimitedOB Multiple GestationsMale PelvisOther_____________________
Breast UltrasoundBilateral Complete
Limited: __Left __Right
ABI’sDuplex ABD Retroperteum
Complete: __Left __Right
Arterial UltrasoundCarotid
Upper Extremity: __Left __Right __BilateralLower Extremity: __Left __Right __Bilateral
Aorta
Biopsy UltrasoundParacentesis
LiverThoracentesis
Breast: __Left __RightOther: _________________________
Thyroid
Venous UltrasoundVenous Doppler Lower Ext:__Left __Right __BilateralVenous Doppler Upper Ext:__Left __Right __BilateralRe�ux Examination__Left __Right __BilateralVein Mapping (Upper)__Left __Right __BilateralGroin
Thyroid Whole BodyThyroid Whole Body with ThyrogenThyroid Uptake/ScanParathyroidHIDA Scan
Gallium ScanRenogram: __Captopril __Lasix
Bone Scan: __Total __Limited __3 PhaseDAT Scan (Parkinson’s)Myocardial Pref (Sestambi)__Treadmill __Lexiscan
__Without injection fraction__With injection fraction (Ensure)
Plumonary Perf and VentGastic Emptying Study: __Solid __LiquidOther: _________________________
Mid Skull/Mid ThighBrain/AlzheimersMelanoma/Thyroid Cancer (Head-Toe)Other: _________________________
MAMMOGRAPHYImplantsMammography (3D Tomo available)__Screening __Diagnostic__Left __Right __BilateralBreast Ultrasound if indicatedMammo Strereotactic Biopsy
Please bring this form and your insurance card with you on the day of your exam.
MR
NUCLEAR MEDICINE
KERN_STANDARD_NEW_REV10282020VER2MC
Schedul ing P: (661) 324-7000 | F : (661) 334-3164
Appointment Date:
Patient’s Name:
Appointment Time: Today’s Date:
Date of Birth:
With & Without Contrast
CT Biopsy
Abdomen (Renals)
ChestHRCT Chest
AbdomenMRCPBreast BilateralPelvis
Brachial Plexus: __Left _Right
Hips: __Left _Right
Joint: ____________ __Left __RightLong Bone: __________ __Left __Right
ColorectalOther: _________________________
FAX this order and clinical records to:
Maps and Addressesare located on theback of this form[ ]
BAHAMAS FACILITY2301 Bahamas Dr.Bakers�eld, CA 93309
RIO BRAVO FACILITY4500 Morning Dr., #202Bakers�eld, CA 93306
RIVERWALK FACILITY9330 Stockdale Hwy., #100Bakers�eld, CA 93311
OLD RIVER FACILITY9900 Stockdale Hwy., #100, #109Bakers�eld, CA 93311
SAN DIMAS FACILITY3838 San Dimas, #A-120Bakers�eld, CA 93301
TEHACHAPI FACILITY432 South Mill Street,Tehachapi, CA 93561(X-Rays ONLY)
DOWNTOWN FACILITY1817 Truxtun Ave.,Bakers�eld, CA 93301
DOWNTOWN ADVANCED FACILITY1818 16th Street,Bakers�eld, CA 93301
KernRadiology.com
KERN RADIOLOGY REFERRAL FOR IMAGING SERVICES
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• Please be advised; failure to present this imaging request at the time of your appointment may result in cancellation and rescheduling of your exam.• Arrive at the speci�ed time to allow for registration and exam preparation.• Notify us upon arrival of any special needs or allergies• You may take and prescribed medication as usual unless speci�ed at the time of scheduling.
• Bring your ID, insurance card and authorization of workers comp information.• Co-pay, co-insurance and/or deductables will be collected at time of service.• Wear comfortable clothing.• Leave valuables at home (Kern Radiology) is not responsible for lost or stolen articles.
• Please allow 1-2 hours for MRI examinations• Alert the technologist if you have ever had metal objects or shavings in your eye.• Remove any jewelry, piercings or valuable items before arriving to your appointment (wedding ring is ok).
• Do not use powder, perfume or deodorant on the day of your exam.• Wear a 2 piece out�t.
• If you are taking calcium and/or other supplements, do not take any 24 hour prior to your exam.
PELVIC/OB/BLADDER • You must �ll your bladder by drinking 32oz. of water, 60 minutes prior to your exam. • DO NOT empty your bladder.ABDOMINAL • Do not eat or drink six (6) hours prior to your exam.
• Please allow 2-3 hours for pet examinations• All diabetic patients should contact Kern Radiology to obtain guidelines on diet and medication restrictions prior to their pet scan• Neurologic studies: no food or liquid for a minimun of six (6) hours prior to arrival. Please check with referring physician regarding all medications you are taking.• Cardiac studies to access cardiac viability: patients should have a high carbohydrated breakfast prior to arrival for their pet scan (e.g. pancakes, cereal, etc).• Body/oncology: no food or liquid for a minimum of six (6) hour prior to arrival for your pet scan, You may have water and normal medications.
• If you are scheduled for a myelogram or a biopsy, do not eat or drink six (6) hours prior to your arrival time. Low Dose Lung (Chest) Screening Follow-up• If you are scheduled for any type of CT Abdomen, CT Pelvic or CT Abdomen/Pelvic with or without contrast, do not eat four (4) hours prior to your arrival time.
General Patient Information
Exam Speci�c Information
General Location & Maps
>>if there is any possibility of pregnancy, please inform our sta� prior to your appointment