RADNET ORANGE COUNTY IMAGING REFERRAL REQUEST … · 5. If possible, dress in loose, comfortable,...
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Appointment Time: _______ Date: ________ Tax ID# 954651287 RADNET ORANGE COUNTY IMAGING REFERRAL REQUEST For all scheduling needs: Fax order / Phone to schedule 784-1643 (P) 285-9084 (F) (714) 387-5000 (P) 753-9030 (F) (949) 299-6230 (P) 627-0923 (F) (562) SEE REVERSE SIDE FOR SITE LOCATIONS AND INFORMATION FOR AUTHORIZATION SUPPORT: To initiate the pre-authorization please include clinical notes with this order PATIENT’S NAME: _________________________________________________________________ DATE OF BIRTH: ________________________ PATIENT’S PHONE: ____________________________________________ ALTERNATE PHONE: _________________________________________ (CLINICAL HX/DX): PROVIDER NAME: (Print) ___________________________________________ SIGNATURE: _________________________________________ CC: PHYSICIAN: ADDRESS: MALE FEMALE TODAY’S DATE: ______________________ CALL PT. TO SCHEDULE STAT ORDER INS. AUTH: ___________________________ LIEN WORK COMP PI PHONE: ______________________________ FAX: __________________________________ Patient to bring images to Doctor CT Contrast Studies Only. Labs must be completed within the past 90 days. Labs needed if: __Hypertension __Age >80 __ Diabetes __ Renal Disease If Labs have been completed within the past 90 days please provide values and fax lab results: Creatinine / GFR ____________ /____________ MRI 3T 1.5T 1.2 OPEN No Preference Brain: IAC’S Pituitary NeuroQuant ® Orbits Spine: Cervical Thoracic Lumbar Sacrum/Coccyx TMJ Brachial Plexus: Left Right Bilateral Sacral Plexus: Left Right Bilateral Soft Tissue Neck Abdomen: Liver Eovist (liver) Kidney Adrenal Glands MRA Renals Pancreas MRCP Enterography Pelvis: Female Pelvis Prostate Joint: Left Right Bilateral Shoulder Elbow Wrist Hip Knee Ankle MR Arthrogram: (with imaging guidance as needed) List Body Part: _____________________ Left Right MRA: Brain Neck Chest Thoracic Aorta Abdomen Abdoment (w/ Contrast) Abdominal w/run-off Renal Arteries Lower Extremity (w/contrast): Left Right MRV: Head Legs/AVF (w/Contrast) Other: Screening Mammogram: Diagnostic Mammogram: Left Right Bilateral Breast Ultrasound (if indicated): Unilateral Bilateral Breast Ultrasound: Left Right Bilateral Breast MRI - Evaluation for Breast CA (w/wo contrast) Breast MRI - Evaluation of implant Integrity (w/o contrast) Date of last mammogram: ______________________ Breast Imaging Extremity: Left Right Bilateral Weight Bearing Non-Weight Bearing List Body Part: _____________________________________________________________ Sinus: Waters Series Spine: Routine AP/LAT Add Flex/Ext Cervical Thoracic Lumbar Chest: 1 View 2 View Special View Rib: Including Chest Left Right Bilateral Abdomen: 2 View KUB AAS Pelvis AP Other:______________________________________________________ X-Ray CT Brain Temporal Bones IAC Middle Ear Mastoids Orbits Maxillofacial - Facial Bones Sinus Neck (Soft Tissue) Spine: Cervical Thoracic Lumbar Upper Extremity Joint: Left Right Bilateral Elbow Wrist Shoulder Lower Extremity Joint: Left Right Bilateral Hip Knee Ankle Extremity (non-joint): List Body Part: _____________________ Left Right Chest: Routine Hi-Res Lung Screen Coronary Calcium Score Abdomen: Liver Pancreas Renal Mass Adrenal Abdomen and Pelvis: Urogram Enterography Stone Protocol Pelvis Other: Head Neck Chest: Aorta PE Abdomen Pelvis Extremity: Upper Lower w/runoff CTA (Angiography) w/ 3D Rendering as indicated w/Contrast w/wo Contrast no Contrast w/ 3D Rendering as indicated w/Contrast no Contrast Doppler if indicated 3D as indicated (No Appointment Required) Arthrography: Left Right Body Part: ________________________________________ Myelogram: Cervical Thoracic Lumbar Esophagram UGI Small Bowel Barium Enema/Lower GI (w/air when indicated) UGIw/SBFT VCUG Cystogram Hysterosalpingogram (HSG) Retrograde Urethrogram Other: Fluoroscopy NaF Bone PET/CT, Skull Bast to Mid-Thigh PET/CT, Whole Body (Melanoma) PET/CT, Brain-Metabolic (FDG) PET/CT, Brain Amyloid PET/CT, Axumin (Prostate) PET/CT, NetSpot GA 68 Notes: PET/CT Bone Density Reason for bone density: _____________________ Date of last exam: DEXA Thyroid Thyroid w/BX: Core FNA w/Afirma Lymph Node Bx Abdomen: Limited Complete Area of concern: Liver Gallbladder Upper Right Quadrant Lower Right Quadrant Renal: w/Bladder Bladder (w/pre and post voiding) Aorta/Retroperitoneal Pelvis (TV if indicated) Hysterosonogram Scrotum/Testicular Venous Doppler (Duplex): Left Right Bilateral Upper Lower Carotid Doppler (Duplex) Arterial Doppler (Duplex): Upper Lower ABI: Segmental Pressures Other: Ultrasound 0-14 Weeks 14 Weeks or Greater Nuchal Translucency OB Ultrasound (TV if indicated) Limited: Viability Heart Beat Position Fluid Placental Location Follow-up -- specify documented problem: Other: OB Ultrasound Neonatal Head Ultrasound (<1yr of age) Spine Ultrasound (<6 months of age) Infant Hips Ultrasound (<1yr of age) Pyloric Ultrasound Other: Pediatric Ultrasound Thyroid Uptake Scan Parathyroid Scan w/spect Lymphoscintigraphy Octreoscan I123 MIBG Scan MUGA (Cardiac Blood Pool) Liver (Hemangioma) Scan Liver/Spleen: w/vascular flow w/o vascular flow Gallbladder (HIDA) with CCK Gallbladder (HIDA) w/fatty meal GI Emptying Scan GI Bleed Scan Meckels Scan Gallium (lmtd) whole body White Blood Cell (WBC) w sulfar colloid Bone Scan: 3-Phase Whole Body SPECT Location: Renal Scan w/Vascular Flow & Function Lasix Captopril HIDA SCAN: w/CCK w/fatty meal w/o EF Other: Nuclear Medicine Thank you for choosing our Imaging Centers www.RadNet.com ORANGE_COUNTY_STANDARD_GENERAL_REF_PAD_03192020VER1MC Scheduling Hours: Mon-Fri / 8am-6pm | For directions and site information see back of this form.
Transcript of RADNET ORANGE COUNTY IMAGING REFERRAL REQUEST … · 5. If possible, dress in loose, comfortable,...
Appointment Time: _______ Date: ________
Tax ID# 954651287RADNET ORANGE COUNTY IMAGING REFERRAL REQUESTFor all scheduling needs:Fax order / Phone to schedule
784-1643 (P)285-9084 (F)(714) 387-5000 (P)
753-9030 (F)(949) 299-6230 (P)627-0923 (F)(562) SEE REVERSE SIDE FOR SITE LOCATIONS AND INFORMATION
FOR AUTHORIZATION SUPPORT: To initiate the pre-authorization please include clinical notes with this order
PATIENT’S NAME: _________________________________________________________________ DATE OF BIRTH: ________________________
PATIENT’S PHONE: ____________________________________________ ALTERNATE PHONE: _________________________________________(CLINICAL HX/DX):
PROVIDER NAME: (Print) ___________________________________________ SIGNATURE: _________________________________________
CC: PHYSICIAN: ADDRESS:
MALE FEMALETODAY’S DATE: ______________________ CALL PT. TO SCHEDULE STAT ORDERINS. AUTH: ___________________________ LIEN WORK COMP PI
PHONE: ______________________________FAX: __________________________________ Patient to bring images to Doctor
CT Contrast Studies Only. Labs must be completed within the past 90 days. Labs needed if: __Hypertension __Age >80 __ Diabetes __ Renal DiseaseIf Labs have been completed within the past 90 days please provide values and fax lab results: Creatinine / GFR ____________ /____________
MRI 3T 1.5T 1.2 OPEN No Preference Brain: IAC’S Pituitary NeuroQuant® Orbits Spine: Cervical Thoracic Lumbar Sacrum/Coccyx TMJ Brachial Plexus: Left Right Bilateral Sacral Plexus: Left Right Bilateral Soft Tissue Neck Abdomen: Liver Eovist (liver) Kidney Adrenal Glands MRA Renals Pancreas MRCP Enterography Pelvis: Female Pelvis Prostate Joint: Left Right Bilateral Shoulder Elbow Wrist Hip Knee Ankle MR Arthrogram: (with imaging guidance as needed) List Body Part: _____________________ Left Right MRA: Brain Neck Chest Thoracic Aorta Abdomen Abdoment (w/ Contrast) Abdominal w/run-off Renal Arteries Lower Extremity (w/contrast): Left Right MRV: Head Legs/AVF (w/Contrast) Other:
Screening Mammogram: Diagnostic Mammogram: Left Right Bilateral Breast Ultrasound (if indicated): Unilateral Bilateral Breast Ultrasound: Left Right Bilateral Breast MRI - Evaluation for Breast CA (w/wo contrast) Breast MRI - Evaluation of implant Integrity (w/o contrast)Date of last mammogram: ______________________
Breast Imaging
Extremity: Left Right Bilateral Weight Bearing Non-Weight Bearing List Body Part: _____________________________________________________________ Sinus: Waters Series Spine: Routine AP/LAT Add Flex/Ext Cervical Thoracic Lumbar Chest: 1 View 2 View Special View Rib: Including Chest Left Right Bilateral Abdomen: 2 View KUB AAS Pelvis AP Other:______________________________________________________
X-Ray
CT Brain Temporal Bones IAC Middle Ear Mastoids Orbits Maxillofacial - Facial Bones Sinus Neck (Soft Tissue) Spine: Cervical Thoracic Lumbar Upper Extremity Joint: Left Right Bilateral Elbow Wrist Shoulder Lower Extremity Joint: Left Right Bilateral Hip Knee Ankle Extremity (non-joint): List Body Part: _____________________ Left Right Chest: Routine Hi-Res Lung Screen Coronary Calcium Score Abdomen: Liver Pancreas Renal Mass Adrenal Abdomen and Pelvis: Urogram Enterography Stone Protocol Pelvis Other:
Head Neck Chest: Aorta PE Abdomen Pelvis Extremity: Upper Lower w/runoff
CTA (Angiography)
w/ 3D Rendering as indicated w/Contrast w/wo Contrast no Contrast
w/ 3D Rendering as indicated w/Contrast no Contrast Doppler if indicated 3D as indicated
(No Appointment Required) Arthrography: Left Right Body Part: ________________________________________ Myelogram: Cervical Thoracic Lumbar Esophagram UGI Small Bowel Barium Enema/Lower GI (w/air when indicated) UGIw/SBFT VCUG Cystogram Hysterosalpingogram (HSG) Retrograde Urethrogram Other:
Fluoroscopy
NaF Bone PET/CT, Skull Bast to Mid-Thigh PET/CT, Whole Body (Melanoma) PET/CT, Brain-Metabolic (FDG) PET/CT, Brain Amyloid PET/CT, Axumin (Prostate) PET/CT, NetSpot GA 68 Notes:
PET/CT
Bone DensityReason for bone density: _____________________Date of last exam:
DEXA
Thyroid Thyroid w/BX: Core FNA w/Afirma Lymph Node Bx Abdomen: Limited Complete Area of concern: Liver Gallbladder Upper Right Quadrant Lower Right Quadrant Renal: w/Bladder Bladder (w/pre and post voiding) Aorta/Retroperitoneal Pelvis (TV if indicated) Hysterosonogram Scrotum/Testicular Venous Doppler (Duplex): Left Right Bilateral Upper Lower Carotid Doppler (Duplex) Arterial Doppler (Duplex): Upper Lower ABI: Segmental Pressures Other:
Ultrasound
0-14 Weeks 14 Weeks or Greater Nuchal Translucency OB Ultrasound (TV if indicated) Limited: Viability Heart Beat Position Fluid Placental Location Follow-up -- specify documented problem: Other:
OB Ultrasound
Neonatal Head Ultrasound (<1yr of age) Spine Ultrasound (<6 months of age) Infant Hips Ultrasound (<1yr of age) Pyloric Ultrasound Other:
Pediatric Ultrasound
Thyroid Uptake Scan Parathyroid Scan w/spect Lymphoscintigraphy Octreoscan I123 MIBG Scan MUGA (Cardiac Blood Pool) Liver (Hemangioma) Scan Liver/Spleen: w/vascular flow w/o vascular flow Gallbladder (HIDA) with CCK Gallbladder (HIDA) w/fatty meal GI Emptying Scan GI Bleed Scan Meckels Scan Gallium (lmtd) whole body White Blood Cell (WBC) w sulfar colloid Bone Scan: 3-Phase Whole Body SPECT Location: Renal Scan w/Vascular Flow & Function Lasix Captopril HIDA SCAN: w/CCK w/fatty meal w/o EF Other:
Nuclear Medicine
Thank you for choosing our Imaging Centerswww.RadNet.comORANGE_COUNTY_STANDARD_GENERAL_REF_PAD_03192020VER1MC
Scheduling Hours: Mon-Fri / 8am-6pm | For directions and site information see back of this form.
Thank you for choosing our Imaging Centers. ORANGE_COUNTY_STANDARD_GENERAL_REF_PAD_03192020VER1MC
Leading Radiology Forward.TM
Anaheim Advanced Imaging
Anaheim Advanced Imaging - X-Ray
Garden Grove Advanced Imaging | BL Women’s Imaging
West Coast Radiology Irvine
Orange Adv./ Orange Imaging Center | BL Women’s Imaging
West Coast Radiology Santa Ana | BL Women’s Imaging
Wave Imaging Laguna Woods
947 S Anaheim Blvd, #130, Anaheim CA 92805
710 N Euclid St, #102, Anaheim CA 92801
9191 Westminster Ave, #105, Garden Grove CA 92844 | BLWI #210
16300 Sand Canyon Ave, #102, Irvine CA 92618
230 S Main St, #101, #205, Orange CA 92868 | BLWI #100
1100-A N Tustin Ave, Santa Ana CA 92705
27882 Forbes Rd, #120, Laguna Niguel CA 92677
714-758-9800
714-517-2099
714-583-6314
949-753-0900
714-288-5400
714-835-6055
949-272-2200
24301 Paseo De Valencia #100, Laguna Woods, CA 93637 949-462-3999
West Coast Radiology PET/CT Center 16300 Sand Canyon Ave, #103, Irvine CA 92618 949-753-0362
Wave Interventional Radiology & Imaging Center 999 N. Tustin Avenue, #5, Santa Ana, CA 92705 657-232-1572
MemorialCare - Huntington Beach 17762 Beach Blvd., #110, Huntington Beach, CA 92647 714-898-2991
MemorialCare - Fountain Valley 18785 Brookhurst St., #102, Fountain Valley, CA 92708 714-417-9950
MemorialCare - Newport Beach 3300 West Coast Highway, #B, Newport Beach, CA 92663 949-646-4400
1441 Avocado Ave., #301, Newport Beach, 92660 949-272-2095
Invision - Newport Beach 280 Newport Center Dr., #100, Newport Beach, CA 92660 949-706-2000
MemorialCare - Irvine 4050 Barranca Pkwy., #160, Irvine, CA 92604 949-726-9500
West Coast Radiology Mission Viejo
675 Camino De Los Mares, #101, San Clemente, CA 92673 949-493-8799
Saddleback Valley Radiology 23961 Calle De La Magdalena, #243, Laguna Hills, CA 92653 949-855-4301
Breastlink Women’s Imaging - Newport Beach
West Coast Radiology Irvine X-Ray 14150 Culver Dr #101, Irvine, CA 92604 949-272-2083
MemorialCare - San Clemente
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Locations, Maps & General Information
GENERAL INFORMATION:
1. IT IS REQUIRED THAT WE HAVE A DOCTOR’S ORDER TO PERFORM YOUR EXAM.
2. Please bring a valid ID card with you along with your insurance card.
3. Some exams require authorization.
4. Please plan on completing registration forms prior to your exam.
5. If possible, dress in loose, comfortable, two-piece clothing. For MRI exams, no belts, or zippers and leave your valuables at home.
6. To expedite your �nal results to your physician, please bring any prior exam reports/images needed for comparison.
7. Study times may vary
Please go to our website
RadNet.com/Orange-County
for exam preparation instructions or
scan this QR code.
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LagunaBeach
Irvine
Fullerton
NewportBeach
HuntingtonBeach
LongBeach
BuenaPark
Lakewood
Los Angeles
DanaPoint
GardenGroveSeal
Beach
Compton
SantaMonica
Downey
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SantaAna
Torrance
ManhattanBeach
LagunaHills
MissionViejo
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Fullerton
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BuenaPark
Lakewood
Los Angeles
DanaPoint
GardenGroveSeal
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MissionViejo
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For all scheduling needs: Fax order or Phone to schedule 784-1643 (P)285-9084 (F)(714) 387-5000 (P)
753-9030 (F)(949) 299-6230 (P)627-0923 (F)(562)
= Open System = 3T MRI = 1.5T MRI O3T 1.5
For Driving Directions, call or visit our website: RadNet.com/Orange-County
