Imaging Orders.docx - IMAGING PLEASE CALL TO SCHEDULE 850.696.4200 – THEN FAX COMPLETED FORM TO 850.607.7553 Name John Doe DOB Time_08:55pm

Imaging Orders.docx - IMAGING PLEASE CALL TO SCHEDULE...

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IMAGING PLEASE CALL TO SCHEDULE 850.696.4200 – THEN FAX COMPLETED FORM TO 850.607.7553 Name John Doe________________ DOB:_01/22/1991________ Time:_08:55pm______________ Pre-Authorization #:___A99999999______________ XRAY o Chest PA and Lateral o Abdomen (KUB) o Abdomen (flat & upright) o Bone Densitometry - DEXA o Extremity R L B _________________________ o Other_________________________________ NUCLEAR MEDICINE o Bone Scan (limited) o Bone Scan (whole body) o Gastric Emptying o Renal Scan (W and WO Lasix ) o Nuclear Stress (Chemical) o Nuclear Stress (Exercise) o Stress Test (Treadmill) o Parathyroid Scan Only o Liver Spleen Scan ____________________________ ULTRASOUND o Abdomen-Complete Prep 1 o Abdomen- RUQ only Prep 1 o Pelvis Prep 3 o Breast R L o Renal Prep 3 o Aorta o Echocardiogram o Scrotum o Thyroid o Pelvic/Transvaginal Prep 3 o Upper Venous Doppler R L B o Lower Venous Doppler R L B ____________________________ CT SCAN Perform BUN & Creatinine BUN/Creat within 45 days Performed on ___________________ BUN _________ Creatinine ________ o Brain - no contrast o Brain (W and WO IV contrast) Prep 1 o Abdomen (W and WO IV contrast) ** Prep 1 o Abdomen (with IV contrast) ** Prep o Abdomen/Pelvis
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Unformatted text preview: (W and WO IV contrast) ** Prep 1 o Abdomen/Pelvis (with IV contrast only) ** Prep 1 o SINUSES/Maxillofacial o Chest (no IV contrast) o Chest (W and WO IV contrast) Prep 2 o RENAL STONE STUDY (no Contrast) o Soft Tissue Neck (W & WO contrast) Prep 2 o Chest/Abdomen/Pelvis (W & WO) ** Prep 1 ____________________________ 02/28/2019 1828 John presents with right side abd pain R10.31, Vomiting R11.0 Abnormal finding on abd US R93.89 Provider ordered a CT ABD/PELVIS W& W/OUT contrast 74178 I spoke with Holly at Cigna 877-482-3625 and she authorized the procedure Auth# A9999999 Andrea Montijo MA-T Patient Preparations 1. Nothing to eat or drink after Midnight or 6 hours before your appointment. 2. Nothing to eat or drink for two hours prior to your appointment. 3. Drink 32 ounces of liquid over the hour before your appointment. You will need a FULL bladder. IMAGING PLEASE CALL TO SCHEDULE 850.696.4200 – THEN FAX COMPLETED FORM TO 850.607.7553 Ordering MD Name Jeramiah B. Joihnson Office Phone 509-222-2222_ Physician Signature JBJ...
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  • Spring '19
  • Holly Burke

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