DATE: 9000 WAUKEGAN ROAD PATIENT’S NAME: SUITE #110 DATE: MORT9000ON WAUKEGAN GROVE, IL 60053 ROAD PATIEPATNPATIENT’ST’SIENT’S NAME: _PHONE#:NAME:______DOB:______AGE:_____ SUITE #110 (O) (847) 213 2700 PATIEPHYSICIAN:NPATIENT’ST’S PHONE #PHONE#:: ______DOB:______9000 Waukegan RoadMORTON Suite GROVE,# 110 IL 60053 (F) (847) 213 2709 CLINICAL HISTORY/INDICATION: Morton Grove, IL 60053(O) (847) 213 2700 PHYSICPHYSICIAN:IAN: ______www.3Timaging.com P: 847-213-2700 F:(F) 847-213-2709 (847) 213 2709 CLINICALCLINICAL HISTOR HISTORY/INDICATION:Y/INDICATION:______www.3Timaging.comwww.3Timaging.com Pre-certifi cation: ______DateRQIPre-certification: # / Pre-Certi c:ation #: ______cc/NAME: ______FAX NUMBER: ____ Exp:DDate:ate: ______cc/NAMPHYSICIAN’Scc/NAME:E:______SIGN_____AT__URE:______FAX N UFAXMB ENUMBER:R:______ICD-10: IExp:CD-9: ______PHYSICPHYSICIAN’SIAN’S SIGNATU SIGNATURE:RE:______If clinicalICD-10: decision support (CDS) software utilized, please specify vendor and approval: PERTINENTIf clinical decision CLINICAL support DIA (CDS)GNOSIS software REQUIRED utilized, please specifyCOMMENTS: vendor and approval: PLEASEPERTINENT PROVIDE SPECIFIC CLINICALM ICD-10RI DIAGNOSISSC CODESREEN IANDNG WHENREQUIRED POSSIBLE: COMMENTS: CT CONTRAST SCREENING SYMPTOMS, LOCATION, DURATION, ANDHISTORY PERTINENT OF WORKING PAST PLEASEPACE PROVIDEMAKER SPECIFIC ICD-10 CODES AND WHEN POSSIBLE: DIABETES IODINE / CT CONTRAST ALLERGY (Please call our office) HISTSYMPTOMS,ORY. (PLEASE LOCATION, DO NOT DURATION, USE “RULE AND WITHOUT”, PERTINENT MET “POSSIBLE”,AL PAST ETC. ) HISTORY.PREGN (PLEASEANT DO NOT USE “RULEOC OUT”,ULAR T R“POSSIBLE”,AUMA ETC.) RENAL DISEASE PREGNANT INTRAVENOUS CONTRAST PER RADIOLOTHOGISTER NON- ODISCRETIONRTHOPEDIC (If you do not select this option, please select a contrast option where applicable.) CEREBRAL ANEURYSM CLIPS METAL IMPLANTS AGE OVER 60 GLUCOPHAGE/GLUCOVANCE WithMETALLICINTRAVENOUS Contrast FOREIGN CONTRAST BODY Without PER Contrast RADIOLOGIST DISCRETION With and (IfWithout you do Contrast not select this option, On-sit eplease BUN/Cr select testing a contrast if needed option where applicable.) IN EYE BUN/CRE Testing @ 3T With Contrast Without Contrast With and Without ContrastIF ANY O F T H E AOn-siteBOVE AR BUN/CrE CHECKE Dtesting, BUN/ if needed CREATININE WITHIN 30 DAYS IS REQUIRED. BUN______Cr______DATE___/___/_____ INTRAVENOMRIUS CONTRAST PER RADIOLOGIST DISCRETIWOON (If yoMEN’Su do not select thIMAGINGis option, please select a contrast option where appCTlicabl eSC.) AN MRI WOMEN’S IMAGING CT SCAN BRAIN / NEURO SCREENING MAMMOGRAPHY (CHECK ALL THAT APPLY) BRAINCT SCAN ______3T MRI WOMEN’S______IMAG______ING (MultideBRAIN tector) BRAIN ☐ BRAIN / NEURO (ROUTINE ) SCREENING ☐ ANNUAL (NOMAMMOGRAPHY SYMPTOMS) (CHECK ALL THAT APPLY) ______SINUSES wo w/wo BRAIN ☐☐ IF ANNUAL INDICAT (NOED, SYMPTOMS)MAY ADD DIAGNOSTIC VIEWS AND/OR ULTRASOUND wo w/wo w BRAIN ______☐ BRAIN (ROUTINE) ______SINUSES ☐ PITUITARY ☐ ORBITS ______DIGITAL☐ IF INDICATED, MAMMOGRAPHY MAY ADD DIAGNOSTIC VIEWS AND/OR ULTRASOUND FACIAL BONES w/☐wo PITUITARY IAC’S ☐ ORBITS DIAGNOSTIC MAMMOGRAPHY WITH ULTRASOUND IF MEDICALLY INDICATED wo FACIAL SI NBONESUSES ______☐ IAC’S ______NECK SOFT TISSUE DIAGNOSTIC Screening☐ B ☐ MAMMOGRAPHYR ☐ L ☐ MA YWITH ADD ULTRASOUND R/L PRN IF MEDICALLY INDICATED w/☐wo IAC’S BRAIN & IAC’S ______w o NECK FSOFTACIAL BTISSUEONES ______MRI NECK (SOFT TISSUE) ☐ B ☐ R ☐ L ☐ MAY ADD R/L PRN ______IAC’s / TEMPORAL BONE MRI NECK (SOFT TISSUE) BREAST ULTRASOUND ☐ BILATERAL ☐ R ☐ L IAC’s / TEMPORAL BONE w/wo ORBITS ______Diagnostic w/wo w NECK SOFT TISSUE ______MRA BRAIN (CIRCLE OF WILLIS) BREAST ☐ W MAMMOGRAPHY ULTRASOUND IF INDIC ☐AT BILATERALED ☐ R ☐ L ______CHEST MRA BRAIN (CIRCLE OF WILLIS) w/wo PITUITARY ☐ W MAMMOGRAPHY IF INDICATED wo CHEST w CHEST ______MRA NECK (CAROTIDS) BREAST ULTRASOUND ______SCREENING CHEST (LDCT) wo MRA NECK (CAROTIDS) ______BREAST MRI W/WO PLEASE CALL SCREENING CHEST (LDCT) wo R L B BREAST BREAST MRI W/WO PLEASE CALL PEw CHESTPE CHEST CTA ______SPINE ☐ CERVICAL ☐ THORACIC OB/GYN ULTRASOUND ______SPINE ☐ LU☐ MBAR CERVICAL ☐ SA☐ CRUMTHORACIC ______PE CHEST CTA wo w/wo CERVICAL SPINE ☐ BONE DENSITY (DEXA) w o w/woABDOMEN w ABDOME N/ /PEL PELVVISIS ______☐ LUMBAR ☐ SACRUM ☐ BONE DENSITY (DEXA) 3T BREAST MRI ______ABDOMEN / PELVIS EXTREMITIESwo w/wo THORACIC SPINE ______w o RENAL Renal ST StoneONE Study STUD Y wo ______EXTREMITIES ______RENAL STONE STUDY wo Rw oL w / wSHOULDERo LUMBAR S P☐IN withE arthrogram DEXAULTR SCANASOUND X-RAY w/woCT UROGRAMCT Urogram w/wo ______R L SHOULDER ☐ with arthrogram ULTRASOUND X-RAY ______CT UROGRAM w/wo R R LL w / wHUMERUSo *BRACHIAL PLEXUS ABDOMEN COMPLETE ORBITS for MRI CERVICAL CERVICA LSPINE SPINE ______R L HUMERUS ABDOMENEC COMPLETEHOCARDIO GRORBITSAM for MRI ______CERVICAL SPINE R L with arthrogram THORACIC SPINE wo ELBO *IntracranialW ☐ MRA LIVER / GB / PANCREAS (RUQ) CHEST PA & LATERAL THORACIC SPINE ______R L ELBOW ☐ with arthrogram 2-DLIVER ECHO / GB / PANCREAS (RUQ) CHEST PA & LATERAL ______THORACIC______SPINE______R L FOREARM KIDNEY / BLADDER ABDOMEN LUMBAR SPINE wo Rw/ wLo FOREARM*Carotid / Ne ck MRA KIDNEY / BLADDER ABDOMEN LUMBAR LUM SPINEBAR SPI NE ______X-RAY ______U__L__T_R__A__S_O___U__N__D______R L WRIST ☐ with arthrogram THYROID ☐ SUPINE ☐ SUPINE / UPRIGHT CT MYELOGRAPHY Rw/ wLo WRISTThorac ic Aorta☐ M withRA arthrogram ORBITHYROIDTS for MRI ABDO☐M ESUPINEN COM P L☐E T SUPINEE / UPRIGHT R L CTB MYELOGRAPHYSHOULDER / ELBOW / WRIST ______R_ _L______R L R HANDL SCRSCROTALOTAL / / TESTICULAR TESTICULAR PELVISPELVIS R L SHOULDERSHOULDER / ELBOW / ELBO /W WRIST / WRIST w/wo HANDAbdom inal Aorta / Renal MRA CHEST PA & LATERAL LIVER / GB / PANCREAS (RUQ) R L B HIP / KNEE / ANKLE / FOOT ______3_ _ _5_ _ _F/E______R L R HIPL HIP ☐ with☐ with arthrogram arthrogram PEPELVICLVIC TRANSABD TRANSABD & & TRAN TRANSVAGSVAG 3 5 F/E CERVICALCERVICAL SPINE SPINE R RL LHIP HIP / KNEE / KNEE / ANKLE / ANKLE / FOOT / FOOT w/ w o *UE/LE Peripheral MRA ABDOMEN complete KIDNEY / BLADDER 3D RECONSTRUCTION ______R L R FEMURL FEMUR CAROTIDCAROTID DOPPLER DOPPLER THORACICTHORACIC SPINE SPINE CTCT CALCIUM CALCIUM SCORE SCORE wo w/wo *NECK SOFT TISSUE ABDOMEN KUB (1 view) THYROID CT Calcium Score ______R L KNEE ☐ with arthrogram AORTA ______3__ _ 5_5_ _ F/E_F/E__ _ __LU___MBAR______SPIN_____E______w_ _contrast R L KNEE ☐ with arthrogram AORTA LUMBAR SPINE CTCT ANGIOGRAPHY ANGIOGRAPHY (CTA) (CTA w contrast) Rw oL w / wLEGo * C(TIBIA/FIBULA)HEST 3 5 F/E CERVICAL SPINE SCROT AL / TESTICSCOLIOSISULAR CT ANGIOGRAPHY (CTA) ______R L LEG (TIBIA/FIBULA) R R L L B B LE LE ARTERIAL ARTERIAL DOPPLER DOPPLER______SCOLIOSIS______☐_☐_ CTA_ _CT_ _HEADA_ HEAD______wo w/wo ABDOMEN THORACIC SPINE PELVI C TRANSABD & TRANSVAG *CAROTID / NECK CTA ______R L R ANKLE/HINDFL ANKLE/HINDFOOTOOT R R L L B B LE LE VENOUS VENOUS DOPPLER DOPPLER______BONE_BONE______AGE _AG___E_ (L_ (L_ _HAND) _HAND______)__ _ ☐_☐_ CTA_ _CT_ _CAROTIDA_ CARO_____TID _/_ NECK _/_ NECK______w o w/w o MRCP 3 5 F/E LUMBAR SPINE OBSTETRICAL -1st TRIMESTER *THO ☐PULMONARY R PULMONARACIC AORTA CCTAYT ACTA ______R L R F LOREF FOREFOOTOOT UEUE LE LE MUSCUL MUSCULOSKELETALOSKELETAL STUD STUDY_Y______☐______☐☐ CTA CT THORACICA THORACIC AORTA AORTA ABDOMENABDOMENwo w/wo /PELVIS CHEST / CHEST PELVwithIwithS Dr Dr.. B. B. Kincai Kincaidd JOINTSOBSTET RANDANDICAL - EXTREMITIES EXTREMITIES2nd / 3rd TRIMES TSPECIFY ESPECIFYR *ABDOMINAL AORTA CTA ______☐_☐_ CTA_ _CT_ _ABDOMINALA_ ABDOMINAL______AORTA__ A__ORT___A__ ☐ LIVER☐ LIVER ☐ MRCP☐ MRCP R LSPECIFY S BPECIFY: H: IP / KNEE R B I OLP H YBSICAL PROFILE R L B UE LE *PERIPHERAL CTA ______☐_☐_ CTA_ _CT_ _AORTAA_ A_ORT___ &A_ _LOW&_ _LO_ _WEXT_ _EXT_ RUNOFF__ RUNOFF__ ☐ PA☐NCREA PANCREASS R L B ARTHROGRAM R L B FOOT / ANKLE R * C AL R O BTID DOPPLER PROSTATE MRI __ _☐_ _ RENAL_☐_ _RENAL______R L B R L B SHOULDER R L B SHOULDER / CLAVICLE AORTA MRI w/wo CONTRAST __ _☐_ _ CHEST_☐_ _ CHEST______OTHER______☐ OTHER: OTHER ☐ OTR HER:L B ELBOW R L B HAND / WRIST R L B LE ARTERIAL DOPPLER OTHER: ______☐ MRA:☐ MRA: X-RAX-RAYY OTHER:OTHER: R L B WRIST R L B RIBS R L B UE LE VENOUS DOPPLER __PEL____PELVIS_VIS______R L B BONY HIP / OSSEO SIU SJOINTS PELVI S R L B HUMERUS / ELBOW / FOREARM UE LE MUSCULOSKELETAL STUDY ______☐______BONY__☐______☐______SI_☐______JOINT______S______☐ UTERUS/OVARIES R☐ L UTERUS/O B KNEEVARIES R L B FEMUR / TIB - FIB OTHER: ______PROSTATE______☐ PROS☐ TATE R L B☐ HERNIA ANKL PROTOCOLE R L FINGER / TOES ______☐ HERNIA PROTOCOL ______SOFT TISSUE SPECIFY R L B☐ FOOT OTHER: ☐ SOFT TISSUE SPECIFY _COMMENTS:______

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