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physicianorder - ORDER FOR OUTPATIENT SERVICES Patient Name...

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Patient Name: Birth Date: Social Security Number: Date of Appointment: Appointment Time: Call Report To: Phone Number to Call: PERTINENT HISTORY/DIAGNOSIS/CLINICAL INDICATIONS FOR SERVICES ORDERED ICD 9 Code(s) To schedule an exam, please call 316.462.2000. TMJs Head/Brain Echocardiography Abdomen (KUB) Orbit, Neck, Face Orbits/IACs Thyroid Abdomen Series Brain Thorax/Chest Chest Ankle __ L __ R Chest Abdomen Breast __ L __ R Cervical Spine Cervical Spine Cervical Spine Abdomen Chest (PA & Lat) Thoracic Spine Thoracic Spine Gallbladder Clavicle __ L __ R Lumbar Spine Lumbar Spine Liver Elbow __ L __ R Pelvis Pelvis Pancreas Facial Bones Joint, Specify: _____________ Abd/Pelvis for kdiney stone Spleen Femur __ L __ R Upper extremity Upper Extremity __L __R Abdominal Aorta Finger(s) __ L __ R Lower Extremity Lower Extremity __L __R Renal __ L __ R Foot __ L __ R MR Arthrogram with Fluoro Sinuses OB Forearm __ L __ R Specify ______________ Soft Tissue neck OB (transvaginal) Hand __ L __ R Abdomen CT Angiogram (CTA) Biophysical Profile Heel __ L __ R Cardiac Specify _________ Transvaginal Hip(s) __ L __ R Other Pelvic (transvag, if indicated) Hips, Bilateral & Pelvis Scrotum w Testicular Duplex Humerus __ L __ R MRA Lower Extremity Arthrogram Extremity-Non Vascular Knee __ L __ R (including distal abdominal aorta) Specify _____________ Carotid Lumbar Spine ___ L ____R ___ Bilat Barium Enema Arterial, Lower Extremity Mandible MRA, Specify: ________ Cystogram, Voiding __ L __ R
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