Radiology Requisition - Lucile Packard Children's Hospital by xiaopangnv

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									                  Lucile Packard Children’s Hospital Stanford
               Lucile Packard Children’s Hospital atat Stanford                         Patient Name (required): ___________________________
                                                                                      Patient Name (required): ___________________________
                                                                                        DOB (required): ___________
                                                                                      DOB (required): ___________
               725 725 Welch Road • Palo Alto, CA 94304
                   Welch Road • Palo Alto, CA 94304
                                                                                        Medical Record Number (if available): ________________
                                                                                      Medical Record Number (if available): ________________
                   www.radiology.lpch.org
               www.radiology.lpch.org
                                                                                      oror Current LPCH Label
                                                                                         Current LPCH Label

        Authorization Services
       Authorization Services                                                      Complimentary Valet Parking
                                                                               Complimentary Valet Parking
        Saturday/Sunday & Evening Appointments
       Saturday/Sunday & Evening Appointments                                     Music, Movies and Exam Preparation to optimize patient’s visit
                                                                                Music, Movies and Exam Preparation to optimize patient’s visit
        3T MRI - Speed CT - Pediatric Sub-Specialty Expertise
       3T MRI - HighHigh Speed CT - Pediatric Sub-Specialty Expertise              Compassionate staff experienced in pediatric patients
                                                                               Compassionate staff experienced in pediatric patients
         ORDERS · RADIOLOGY REQUISITION
       ORDERS · RADIOLOGY REQUISITION                                      Scheduling (650) 497-8376 Fax (650) 724-2663
                                                                         Scheduling (650) 497-8376 Fax (650) 724-2663
      INSURANCE Provider:__________________________________________ Policy#:_________________________Phone#:___________________
INSURANCE Provider:__________________________________________ Policy#:_________________________Phone#:___________________
      (Insurance card (front & back) must be faxed if patient is not a current LPCH Patient)
(Insurance card (front & back) must be faxed if patient is not a current LPCH Patient)
      SCAN:  Routine  Time sensitive; requirement ______________________________  STAT; reason ________________________________
SCAN:  Routine  Time sensitive; requirement ______________________________  STAT; reason ________________________________
      Will exam need to be coordinated with other tests/appt?  No  Yes if yes, please specify__________________________________________
Will exam need to be coordinated with other tests/appt?  No  Yes if yes, please specify__________________________________________
      Special Needs:  Translator, Language:_________________________  Other:___________________________________________________
Special Needs:  Translator, Language:_________________________  Other:___________________________________________________
      PARENT/Legal Guardian’s Name:____________________________ Specify relationship to patient (Mother, Father, etc.): __________________
PARENT/Legal Guardian’s Name:____________________________ Specify relationship to patient (Mother, Father, etc.): __________________
      Best time to contact Parent/Legal Guardian:_____________ Phone#:____________________________ Cell#:_____________________________
Best time to contact Parent/Legal Guardian:_____________ Phone#:____________________________ Cell#:_____________________________
      Check one:  Call Family to schedule  Call Office to schedule (name/phone):______________________________________________________
Check one:  Call Family to schedule  Call Office to schedule (name/phone):______________________________________________________
      DIAGNOSIS (ICD-9 Required):___________________ Symptoms:_________________________________________________________________
DIAGNOSIS (ICD-9 Required):___________________ Symptoms:_________________________________________________________________
      Clinical concern:________________________________________________________________________________________________________
Clinical concern:________________________________________________________________________________________________________
      Underlying/Provisional Diagnosis:__________________________________________________________________________________________
Underlying/Provisional Diagnosis:__________________________________________________________________________________________
                                                                 Report Results:  Routine  Stat
                                                              Report Results:  Routine  Stat
       MRI*  Contrast              W/O Contrast                                  ULTRASOUND                    *Does patient have the following:
 MRI*  Contrast 3D Reconstruction
                 With          W/O Contrast                                    ULTRASOUNDif necessary
                                                                                    W/Doppler                  *(Required for have the following:
                                                                                                                 Does patient MR/CT/Fluoroscopy)
           With 3D Reconstruction
        Brain                                 Spine                              W/Doppler
                                                                                   Abdomen if necessary       (Required for MR/CT/Fluoroscopy)
                                                                                                                 Yes No
  Brain ________________________ Spine Cervical  Thoracic
                                                                                  Abdomen
                                                                                   Abdomen Limited            Yes No Allergies
                                                                                                                    
           ________________________  Cervical  Thoracic
     ________________________                     Lumbar                             Single organ:____________
                                                                                  Abdomen Limited                 Allergies Sedation Event
                                                                                                                     Adverse
        Brain w/MRA
     ________________________                  Chest
                                             Lumbar                                Kidney and Bladder
                                                                                   Single organ:____________         Adverse Anesthesia Event
                                                                                                                   Adverse Sedation Event
                                                                                                                     CNS Abnormalities
                                                                                                                   Adverse Anesthesia Event
  Brain ________________________ Chest
           w/MRA                                 ________________________   Kidney Transplant
                                                                                   Kidney and Bladder
        Abdomen                                                                                                     Apnea/Snoring
                                                                                                                   CNS Abnormalities
     ________________________                  Chest w/MRA
                                            ________________________   TesticularKidney Transplant
  Abdomen ________________________ Chest w/MRA ________________________   Testicular With Doppler
                                                                                   Testicular
                                                                                                                     Apnea/Snoringissue
                                                                                                                   Other Airway
        Abdomen & Pelvis
                                                                                                                     Lung Airway issue
                                                                                                                   Other Disease/Asthma
     ________________________                  Cardiac                            Testicular With R  L
                                            ________________________   Extremity  Doppler
           ________________________ Cardiac                                          Upper:______________
                                                 ________________________  Extremity  R  L                      Development Delay
                                                                                                                     Lung Disease/Asthma
  Abdomen & Pelvis                                                                                                  History of Renal Disease
        Abd & Pelvis w/MRA                      ________________________   Lower:_______________                Development Delay
     ________________________               ________________________                  Upper:______________
                                               Extremity/Joint
           ________________________ ________________________                                                       History of Cancer
                                                                                                                     History of Renal Disease
  Abd & Pelvis w/MRA                                                                Vascular
                                                                                      Lower:_______________
        Other:                                   ________________  R  L
                                                                                                                     Sickle of
                                                                                                                   HistoryCellCancer
     ________________________  Extremity/Joint                                      Non Vascular
                                                                                      Vascular                       Cardiac Disease
                                                                                                                   Sickle Cell
  Other:                                         ________________  R 
                                             ________________  R  L L             Other:
                                                                                    Non Vascular                    Previous CT
                                                                                                                   Cardiac Disease
                                                             X- RAY / R  L  Other:
       CT*  Contrast  W/O Contrast ________________  FLUOROSCOPY*                                                 Previous MRI
              With 3D Reconstruction                                                                              Previous CT
 CT*  Contrast  W/O Contrast                           X- RAY / FLUOROSCOPY*                                       Previous Contrast Reaction
        Brain 3D ReconstructionAbd & Pelvis
                                                             Chest PA/AP             Cervical Spine             Previous MRI
         With                                                                                                     Previous Contrast Reaction
                                                              Chest 2V                  _____________________   If required, do you authorize an
  Brain _______________ Abd Abdomen (only)  Chest PA/AP
                              & Pelvis                                            Cervical Spine
                                                              Extremity/Joint         Thoracic Spine           anesthesia consult?  No  Yes
           _______________  Spine                        Chest 2V                    _____________________
     _______________  Abdomen (only)                           _________  R  L        _____________________ If required, do you authorize an
        Facial Bones                                     Extremity/Joint          Thoracic Spine              If yes, provide History and
                                                                                                                anesthesia consult?  No  Yes
     _______________  Spine Cervical
                                                               _________  R  L  Lumbar Spine
                                                                                                                 Physical with order/request.
                                                             _________  R  L
                                                              Abdomen                 _____________________
                                                                                         _____________________ If yes, provide History and
        Sinus
  Facial Bones                     Thoracic
                               Cervical                                              Lumbar
                                                             _________  R  L   VCUG Spine
                                                                _______________
        Chest                      Lumbar                                                                     Physical with order/request.
  Sinus                       Thoracic                  Abdomen
                                                              Pelvis                  _____________________
                                                                                       UGI                       If female patient, has she started
           _______________  Cardiac                         _______________
                                                              Scoliosis              VCUG
                                                                                     UGI with SBFT              her period?
  Chest                       Lumbar
                                    ____________  Pelvis
        Chest, Abd & Pelvis                                    _______________                                    female Yes
                                                                                     Modified Barium Swallow If No patient, has she started
                                                                                      UGI
     _______________  Cardiac      ____________  Scoliosis                        UGI with SBFT              her period?
       Other:                 ____________                     _______________        BE                        Certain imaging exams require
  Chest, Abd & Pelvis           Extremity                  _______________        Modified Barium Swallow      No  Yes
                               ____________ L                Other:                                             a pregnancy test
                                    _______R                                                                   Certain imaging exams require
 Other:                                                     _______________        BE
                             Extremity
                                                                                                                a pregnancy test
      PRACTICE/Clinic: ______________________________Phone#:___________________Fax#: _________________ Pager# ___________
                                                          Other:
                               _______R L
      Primary Care Physician (Print Name) _______________________________________________________________________________
                                                                                                                                                             Rev (2/10) (2/10)




PRACTICE/Clinic: ______________________________Phone#:___________________Fax#: _________________ Pager# ___________
      DATE          TIME        Ordering Provider Signature:
                                                                                                                                                                     Rev




Primary Care Physician (Print Name) _______________________________________________________________________________
                                 PRINT Name:                                     Credentials:          Pager Number If applicable:
                                                                                                                                                      L14283.12.04




DATE          TIME          Ordering Provider Signature:
       DATE          TIME        Packard Provider Signature:
                            PRINT Name:                                       Credentials:           Pager Number If applicable:
                                 PRINT Name:                                     Credentials:          Pager Number If applicable:
                                                                                                                                                 283.12.04




DATE          TIME          Packard Provider Signature:
            Lucile Packard Children’s Hospital at Stanford                                                  PATIENT INFORMATION
            725 Welch Road • Palo Alto, CA 94304                                 Radiology Services
            www.radiology.lpch.org                                  Scheduling (650) 497-8376 • Fax (650) 724-2663

              DIRECTIONS TO HOSPITAL
          From US Highway 101 North or South
   Take the Embarcadero Rd. exit West. Cross El Camino Real                                                                                                                          N


  (becomes Galvez St). Turn right at Arboretum Rd, cross Palm                                               Sand Hill Rd.
                                                                                                                                                                      W                  E


      Drive. Turn left on Quarry Rd. Turn right on Welch Rd.                          .
                                                                                                                                                      Sa
                                                                                                                                                           nd                        S                                                                Palo Alto
                                                                                  e Rd                                                                          Hil
                                                                           Alpin                                                                                      lR
                                                                                                                                                                           d.
                      From Highway 280                                                                                                                 We
                                                                                                                                                          lch
                                                                                                                                                                  Rd.
     Take the Sand Hill Road exit East. Turn right on Pasteur




                                                                                                                                   Pasteur Dr.
                                                                                                     Campus Dr.                                  Blake Wilbur
               Drive. Turn left onto Welch Road.




                                                                                     Junipero Serra Blvd.




                                                                                                                                                                                                                      El Camino Real
                                                                         To                                                                                                                                                                                             To




                                                                                                                   Campus Dr.
                                                                        San                                                                                                                                Stanford                                                    San
                                                                      Francisco                                                                                                                            Shopping                                                  Francisco
                                                                                                                                                                725
                    WHERE DO I GO?                                                                                               Stanford
                                                                                                                                                                                                            Center

                                                                                                                                 Hospital
                                                                        280                                                                                                                                                                                            101




                                                                                                                                                                                                                                                      Alma
                                                                                                                                 & Clinics

                ANESTHESIA Patients                                                                                                                        Lucile Packard
                                                                                                                                                           Children’s
                                                                                                                                                                                               Quarry Rd.




                                                                                                                                                                                                                                  Cal Train Station
                                                                        To                                                                                                                                                                                             To
       Please go directly to the Ford Family Center                   San Jose                                                                             Hospital                                                                                                  San Jose




                                                                                                                                                                                               Arboretum
              located on the Ground Floor
                                                                         Emergency Service                                                                                          Palm Dr.                                                            University




                                                                                                                                                                       Campus Dr.
                     All Other Patients                                  Public Parking
                                                                         Map not to scale
                                                                                                                                Stanford
                                                                                                                                University

      Please go directly to Admitting (immediate right                                                                                                                              Galvez                                                             Embarcadero

     once you enter the hospital) and then proceed to
        1st floor Radiology (next to the train station)

                                      PATIENT MUST PROVIDE 2 FORMS OF
                                    I.D. (Name/Date of Birth)PRIOR TO EXAM
                                         AT REGISTRATION and PARENT/
                                     GUARDIAN MUST PROVIDE PICTURE ID
              Pregnancy Policy: Please note, female patients who have started having menstrual periods may be
                                           required to complete a pregnancy test

                                Exam Preparation and Arrival Instructions
WHEN is our Scan?
The scheduling department will be contacting you to schedule this appointment. The scheduling process for your child’s exam
requires several important pre-screening steps. You will be contacted within 24 hours.
WHERE do I PARK?
From Welch Road, turn into the Hospital Entrance. Complimentary Valet Parking is available from 6am-6pm (Mon-Fri) as well
as Complimentary Self-Parking.
WHAT TIME should we ARRIVE for our Scan?
We customize the pre-scan preparation process for every child! We will provide you with an ARRIVAL TIME on your appoint-
ment date. Please plan accordingly, failure to arrive at your assigned time may result in long delays or your examination being
rescheduled to another day.
WHERE do we go for our MR or CT exam?
-Are you an ANESTHESIA patient? Proceed directly the the Ford Family Center (on the ground floor). -All NON anesthesia pa-
tients can proceed directly to ADMITTING (immediate right once you enter the hospital) and then you will be directed to 1st
floor Radiology (next to the train station) -If your child is not a current LPCH patient, please bring a list of ALL MEDICATIONS
your child takes, and all previous procedures (surgeries, implants, etc.).
WHERE do we go for our ULTRASOUND, X-RAY, or FLUOROSCOPY exam?
-Proceed directly to ADMITTING (immediate right once you enter the hospital) and then you will be directed to the 1st floor Ra-
diology (next to the train station)

ANESTHESIA Patients - special instructions
The parent/legal guardian will be contacted 1-2 days prior to your scan by a Nurse to obtain further patient history and review
specific patient preparation anesthesia instructions. If for some reason this has not occurred, please call Scheduling
(650-497-8376) 1-2 days before your visit.

								
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