Sheduling HOTLINE: 1-877-507-XRAY (9729) | Scheduling HOTLINE FAX: 1-877-765-7729MRI

RADIOGRAPHIC EXAMINATION

ULTRASOUND

CTIV Contrast*

Radiologist DiscretionWith

BrainIACs/7th & 6th Nerve-Includes limited brain(w/ and w/o contrast)MRA Brain Carotids RenalOrbits- Includes limited brainPituitary/Sella- Includeslimited brain (w/ and w/o contrast)TMJ

WithoutWith and Without

*If more than one MRI test is orderedwrite contrast choice next to each procedure.

IV Contrast*Radiologist DiscretionWith WithoutWith and Without

*If more than one CT test is orderedwrite contrast choice next to each procedure.

Brachial Plexus R LSoft Tissue Neck(structures otherthan C-Spine)Trigeminal Nerve

C-SpineT-SpineL-Spine

HEADHeadOrbitsParanasal SinusParanasal Sinus StereotacticProtocol:_______________Temporal BonesFacial Bones

HEAD

CervicalThoracicLumbarNeck-Soft Tissue

SPINEAnkleElbowFootKneeShoulderWrist

EXTREMITY

AbdomenAbdomen/Pelvis Renal Protocol (Mass) (IV Contrast Needed) Appendix Protocol - Abdomen & Pelvis (IV and Oral Contrast Needed) Urogram-Stone Protocol (No Contrast Needed) Enterography (Contrast Needed) Pelvis (IV and Oral Contrast Needed)

ABDOMENChestChest - High ResAngiogram

CHEST

SPINEAnkle(Hind Foot)ElbowFoot(Mid foot to toe)ForearmHips - BilateralHipsHumerusKneeLower LegShoulderThighWrist

EXTREMITY

Abdomen Complete (Flat & Upright KUB)Acute Abdominal Series(Flat & Upright KUB Including PA Chest)KUBChestRibs_____Right_____Left (Including PA Chest)ClavicleFacial BonesMandibleTMJNasal BonesSkullSinusesSoft Tissue NeckFootToeAnkleTib/FibFemur

Boney PelvisCoccyxFemale PelvisMale Pelvis (Prostate)Sacrum

PELVIS

Abdomen (Specify)________________MRCP

ABDOMEN

OTHER

R L R LR L R L

R LR LR LR LR LR LR L

R LR LR LR L R LR L

R LR L

R LR LR L

R LR LR L R L

KneeHandFingerShoulderHumerusForearmWristElbowPelvisHipCoccyxSacrumLumbar SpineCervical SpineThoracic SpineScoliosis Series

Abdomen - CompleteAbdomen - Limited(RUQ/Gallbladder)AortaArterial Upper Ext. Lower Ext. CarotidOB

Pelvic (Woman-Transvaginal as indicated)Transvaginal OnlyRenal (Kidneys & Bladder)Renal (Kidneys Only)Soft Tissue _____________________(specify)Testicular (Scrotum Doppler for arterial inflowand venous outflow as required)Thyroid (Neck)Venous Upper Ext. Lower Ext.

R LR LR LR L R LR LR LR L

R L

Ltd. CompleteLtd. CompleteLtd. CompleteLtd. Complete

*ALL EXAMS SEEN ON WALK-IN BASIS*Creatinine acuired on site at time of exam--IMMEDIATE RESULTS

(X-Rays done on a work-in basis, please bring slip from doctor) Perform 3-D Reconstruction Yes

Other (Specify):_________________________________________________________________

Other_____________________________________________________________

Other_____________________________________________________________

RP-NC-COAS_Rev. 11/2015

3606 Henderson Dr.Jacksonville, NC 28546Office: 910-937-7226 Fax: 910-937-0064www.NCDiagnosticImaging.com

COASTAL DIAGNOSTIC IMAGING

Patient’s Name:______________________________________________________________________________________Date of Birth________/__________/__________

Telephone: Primary (_______)____________________________Secondary (_______)_______________________________Other (_______)_________________________

Appointment Date:________________________Appointment Time:___________AM / PM

STAT Call Report to: (phone)_____________________________________ After 5:00 Please Call:(phone)____________________________________ Fax STAT Report to:____________________

Insurance _____________________________________________________________________________________________________________________________________________________

Scheduling HOTLINE Phone: 1-877-361-4757Scheduling HOTLINE Fax: 1-877-361-4855

Where specifically is the problem/pain located? ____________________________________________________________________________________________________How did the problem/injury occur? ______________________________________________________________________________________________________________When did the symptoms start/injury occur? _______________________________________________________________________________________________________What has been the previous treatment, if any? _____________________________________________________________________________________________________Additional pertinent information or relevant codes __________________________________________________________________________________________________

Physician Name (Printed)______________________________________________________________ Physician Phone:_________________________Physician Signature:___________________________________________________________________ Date:___________________________________

Please fax front & back of patient’s insurance card and any clinical information.

Traveling US Hwy 17 Northbound:1. Turn left onto Gumbranch Rd.2. Turn right onto Henderson Drive3. Coastal Diagnostic Imaging will be at 3606 Henderson Drive on the right

Traveling US Hwy 17 Southbound:1. Turn right onto Western Blvd.2. Turn left onto Henderson Drive3. Coastal Diagnostic Imaging will be at 3606 Henderson Drive on the left