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Referral Form MSN Imaging by MikeJenny

VIEWS: 12 PAGES: 2

									                                                         REQUEST FORM
                                                Call 216-688-8000 For Appointments
                                                     Fax Number: 216-688-0075

Name:                                                                                          Date:

Physician Name:                                                                                Fax Number:

Diagnosis/Symptoms:

                         PLEASE HAVE YOUR INSURANCE CARD AT THE TIME OF YOUR EXAM
              PLEASE CHECK APPROPRIATE EXAM. IF EXAM IS NOT LISTED, PLEASE WRITE NEXT TO OTHER.

               X-RAY                                        MRI                                                 CT SCAN
         ABDOMEN/KUB                       ANKLE                                       R   L       ABDOMEN (prep)
         ANKLE                  R   L      BRAIN                                                   PELVIS (prep)
         BARIUM SWALLOW                    FOOT                                        R   L       RENAL STONE PROTOCOL (prep)
         CALCANEOUS             R   L      HAND                                        R   L       BRAIN
         CLAVICLE               R   L      HIP                                         R   L       BONE DENSITY
         CHEST (PA & LAT)                  KNEE                                        R   L       EXTREMITY_____________________         R L
             Apical/Lordotic              MRA BRAIN                                               LUNG/CHEST (NPO 3 hours)
         ELBOW                  R   L      MRA CAROTIDS                                            NECK
         FACIAL BONES                      SHOULDER                                    R   L       SINUS
         FEMUR                  R   L      SPINE (specify level)________________                   SPINE (specify level)_______________
         FINGER________         R   L      WRIST                                       R   L       CT GUIDED BIOPSY
         FOOT                   R   L      OTHER                                                      Specify level:_________________
         FOREARM                R   L                 ULTRASOUND                                   OTHER
         HAND                   R   L      ABI (claudication)                                              MAMMOGRAPHY
         HUMERUS                R   L      AORTA (NPO 12 hours)                                    ANNUAL SCREENING
         HIP                    R   L      ARTERIAL DOPPLER                                        DIAGNOSTIC UNILATERAL                  R L
         IVP (prep)                           Specify area:___________________        R   L       DIAGNOSTIC BILATERAL
         KNEE                   R   L      BREAST                                      R   L            SPECIAL PROCEDURES
         NASOPHARYNX                       CAROTID                                                 AORTA/BILATERAL/FEMORAL
         PATELLA                R   L      GALLBLADDER                                             ABDOMINAL (SMA/IMA/CELIAC)
         PELVIS                            GRAFT Specify:__________________                        DISCOGRAM:
         RIBS                   R   L      HYSTEROSONOGRAM                                            Specify level:_________________
         SI JOINTS                         LIVER (NPO 12 hours)                                    DSA CAROTIDS/CEREBRAL
         SACRUM/COCCYX                     OBSTETRICAL                                             FISTULAGRAM
         SCAPULA                R   L         <14 weeks (full bladder prep)                       MYELOGRAM:
         SCOLIOSIS                            >14 weeks (full bladder prep)                          Cervical
         SHOULDER               R   L         BPP                                                    Thoracic
         SMALL BOWEL                          OB TRANSVAGINAL                                        Lumbar
         SPINE:                            PANCREAS (NPO 12 hours)                                    Total
             Cervical                     PELVIS (full bladder prep)                              PERCUTANEOUS NEPHROSTOMY
             Lumbar                       PROSTATE (Fleet enema prep)                             PERCUTANEOUS BILIARY TUBE
             Thoracic                     RENAL                                                   PERM CATH
         TIB FIB                R   L      RENAL DOPPLER                                           PICC LINE
         TOE________            R   L      RUQ (liver, pancreas, gallbladder) (prep)               PORT PLACEMENT
         WRIST                  R   L      SCROTAL                                                 UPPER / LOWER EXT. ANGIOGRAM           R L
         OTHER                             SPLEEN (NPO 12 hours)                                   UPPER / LOWER EXT. VENOGRAM            R L
                                           THYROID
                                           TRANSVAGINAL                                                LAB RESULTS AND/OR A PREP
                                           VENOUS (r/o DVT)                                             ARE NEEDED FOR SPECIAL
                                              Upper extremity                         R   L                  PROCEDURES
                                              Lower extremity                         R   L
         IF AN EXAM IS NOT LISTED, PLEASE WRITE IT IN THE BOX BELOW.




                                        PHYSICIAN SIGNATURE:
1/2006
                                             Medical Specialists Center
                                                  MSNImaging
                                              4330 West 150th Street
                                                  216/688-8000
                                              www.msnimaging.com

Directions: From I-71, take the West 150th Street exit. Turn South onto West 150th Street (a right turn from both the
North and South). The Medical Specialists Center will be on the right.

								
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