WAKE FOREST UNIVERSITY                                                                Patient Name:    ___________________________________
     BAPTIST MEDICAL CENTER                                                                        MRN:     ___________________________________
     CARDIOVASCULAR MRI                                                                             Date:   ___________________________________
     IMAGING REQUEST FORM                                                                  Referring MD:    ___________________________________

     CALL to schedule at (336) 716-8663 then                                       This form is not for medical records, for internal use only.
     FAX form & SCRIPT to (336) 716-8683

     STUDY REQUESTED: Place an “X” in each appropriate box
X    STUDY                                                                                                                                             ORDER CODES
                                                                                                                                                       (WFUBMC use only)
    Cardiac MRI Valve Disease and/or cardiac output – Aortic, mitral, tricuspid and/or pulmonic valves.              9701
    Cardiac MRI for Morphology & Function (Lt Heart) –Masses, cardiomyopathy, pericardium, myocarditis and toxicity. 9702
    Cardiac MRI for Morphology & Function (Right Heart) – ARVD, RVOT disease, masses, etc.                           9703
    Cardiac MRI for Morphology & Function Without Contrast-LV Regional Wall Motion and EF Only                       9720
    Cardiac MRI Iron Overload Assessment – Hemachromatosis, transfusions, thalassemia                                9704
    Cardiac MRI Iron Overload + Flow Velocity-Iron Overload plus flow velocities                                     9717
    Cardiovascular MRA Pulmonary Vein Evaluation + 3D – Orientation of pulmonary veins pre/post ablation.            9705
    Cardiovascular MRA Chest w/wo Infusion + 3D – Dissection, aneurysm, coarctation.                                 9706
    Cardiac MRI of Coronary Arteries – Anomalies, proximal course of coronary arteries.                              9707
    Cardiac MRI Congenital Work-up – Requires phone call to physician.                                               Call MRI physician
    Cardiac MRI Adenosine Stress (Perfusion) – Myocardial ischemia and viability.                                    9708
    Cardiac MRI Dobutamine Stress (Wall Motion) – Myocardial ischemia and viability.                                 9709
    Cardiac MRI Dobutamine Stress Without Contrast-Wall Motion Only                                                  9711
    Cardiac MRI Exercise Stress Without Contrast-Wall motion only, Myocardial Ischemia                               9712
    Cardiac MRI Exercise Stress (Wall Motion) – Myocardial ischemia.                                                 9710, Routine Stress EKG
    Cardiac MRI Stress & Flow Velocities Without Contrast-CMRI Stress plus Flow Velocities                           9718
    Cardiac MRI Stress, Flow Velocities, With & Without Contrast-CMRI Stress plus Flow Velocities                    9719
  1. NPO for 6 hours, except for medications.
  2. No caffeine for 24 hours, including tea, soft drinks, chocolate, and decaffeinated products.
  3. No theophyline containing products for 24 hours.
RELEVANT SIGNS/SYMPTOMS DIAGNOSIS: (Mandatory – Must be in ICD-9 Numeric Code) **Circle below or enter code in this space

               Code       Sign/Symptom                                                            Code          Sign/Symptom
              786.50      Chest pain, unspecified
              786.51      Precordial chest pain                                                   746.89        Other congenital anomaly, heart
              786.59      Pressure, tightness in chest                                            745.2         Tetralogy of Fallot
              412.        Old myocardial infarction                                               745.4         VSD
              410.12      AMI, anterior wall                                                      745.5         Ostium Secundum, ASD
              414.9       Chronic ischemic heart disease                                          746.2         Other endocardial defects
              413.1       Prinzmetal angina                                                       746.9         Unspecified congenital anomaly of the heart
              411.1       Unstable angina                                                         745.10        Complete transposition, great vessels
              411.89      Coronary artery disease                                                 745.12        Corrected transposition, great vessels
                                                                                                  746.89        Other congenital anomaly, heart
                                                                                                  746.85        Coronary artery anomaly, congenital
              746.4       Congenital insufficiency of aortic valve
              424.0       Mitral valve disorders
              424.1       Aortic valve disorders                                                  427.0         Paroxysmal supraventricular tachycardia
              424.2       Tricuspid valve disorders                                               427.1         Paroxysmal ventricular tachycardia
              785.2       Undiagnosed cardiac murmur                                              780.2         Syncope and collapse, vasovagal attack
              424.90      Endocarditis, valve Unspecified, cause unspecified                      427.31        Atrial fibrillation
                                                                                                  427.1         Paroxysmal ventricular tachycardia
                                                                                                  426.3         Left bundle branch block
              786.05      Shortness of breath                                                     427.9         Arrhythmia
              416.0       Primary pulmonaryhypertension                                           426.7         Wolfe-Parkinson White syndrome
              425.4       Other primary cardiomyopathies                                          785.1         Palpitations
              428.1       Left heart failure                                                      780.4         Dizziness
              429.3       Cardiomegaly
              402.10      Hypertensive heart disease, benign, without CHF
              782.3       Edema, localized NOS                                                    441.4         Abdominal aneurysm w/o mention of rupture
              402.91      Hypertensive heart disease, with congestive heart failure               747.3         Anomalies of pulmonary artery
              786.09      Other respiratory distress                                              747.29        Other anomalies of aorta
              428.0       Congestive heart failure                                                759.82        Marfan’s syndrome
              425.1       Hypertrophic obstructive cardiomyopathy                                 441.2         Thoracic aneurysmw/o tention of rupture
              674.84      Postpartum cardiomyopathy                                               417.0         Arteriovenous fistula of pulmonary vessels
              429.0       Myocarditis                                                             747.1         Coarctation of aorta
              277.3       Amyloidosis
              963.1       Exposure to antineoplastic drugs and immunosuppressive drugs
              250.0       Diabetes                                                                861.01        Cardiac contusion
              276.6       Fluid overload disorder                                                 997.1         Cardiac complications

              164.1       Malignant neoplasm, heart
              212.7       Benign neoplasm, heart
              423.2       Constrictive pericarditis
              423.9       Unspecified disease of pericardium
              999.9       Other

     {revised 05-06-08}

                                   Physician (or Designee) Signature:                         _____________________________________________

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