OUTPATIENT SERVICES Medical Imaging/Diagnostic Testing Miami Valley Hospital Atrium Medical Center Upper Valley Medical Center To schedule an appointment call: (937) 499-7364, (855) 887-7364 (toll free) or fax order to: (937) 641-2336 *Indicates items required for a complete order *Patient Name (printed): Date of Birth:

Patient Phone #: Patient Alternate #: Insurance:

*ICD Diagnosis Code(s) Symptoms or Complaint:

*Physician Name (printed): *Date: *Time:

*Physician Signature: Special Instructions:

GENERAL XRAY ULTRASOUND NUCLEAR MEDICINE/PET Abdomen/Series Abdomen Complete Bone Scan Whole Body Abdomen/KUB Abdomen Limited (ie: RUQ) 3-phase Limited Cardiac Stress: Pharmacological Treadmill Chest Biophysical Profile Bladder MUGA Scan Sinus Breast Limited R L BIL Gall Bladder w/CCK w/o CCK Pelvis Breast Complete R L BIL Gastric Emptying Liquid Solid Skull Kidney Gallium Soft Tissue neck OB Spine Cervical Lumbar Thoracic Transvaginal if indicated Lung Scan ventilation/perfusion w/Obliques Pelvis Parathyroid w/Flexion & Extension Transvaginal if indicated Renal – Specify: Testicular Flow/function x/Lasix w/Captopril Sacrum/Coccyx Thyroid Thyroid Uptake/Scan Ankle R L BIL Other – Specify: PET/CT-Specify: Elbow R L BIL VASCULAR ULTRASOUND Other – Specify: ABI only Femur R L BIL CT Foot R L BIL Arterial Duplex All exams listed below are contrast per radiologist protocol. For Arterial Doppler Study/PVR Forearm R L BIL specific contrast request, indicate under Other. Lower Upper Abdomen Hand R L BIL Carotid Hip R L BIL Vein Mapping Lower Upper Abdomen/Pelvis Humerus R L BIL R L BIL Chest Knee R L BIL Venous Doppler Studies Lower Upper R L BIL Extremity-Specify: Lower Leg R L BIL Other – Specify: Head Ribs R L BIL CARDIOLOGY Neck Shoulder R L BIL 12-Lead ECG Pelvis Wrist R L BIL 24-Hour Holter Monitor Spine: Cervical Other – Specify: 48-Hour Holter Monitor Thoracic FLUOROSCOPIC PROCEDURES 2-D Echo Lumbar Arthrogram: specify ECHO Treadmill Dobutamine CT Angiography-Specify: w/CT w/MRI Stress EKG (Treadmill only) CT Lung Screening Cystogram voiding Cardiac Nuclear Stress: Medicated Treadmill *Other – Specify: Hysterosalpingogram MUGA Scan Esophagram Event Monitor MRI All exams listed below are contrast per radiologist protocol. For Upper GI Other – Specify: specific contrast request, indicate under Other. Small Bowel RESPIRATORY Abdomen Barium Enema/Colon w/air ABG w/O2 (specify lpm) w/o O2 Intravenous Pyelogram (IVP) Complete PFT (includes volumes and diffusion) Ankle R L BIL Modified barium swallow/video fluoroscopy Complete PFT with Bronchodilator (includes volumes, Brachial Plexus MAMMOGRAPHY diffusion and bronchodilator) Breast Spirometry (includes SVC and FVC) Screening Mammogram Fast Breast Screening Spirometry with bronchodilator (includes SVC, FVC and Screening Mammogram with 3D bronchodilator) Chest Diagnostic Mammogram R L BIL Pulmonary Exercise Stress test Elbow R L BIL Breast Imaging Workup/Diagnostic/Mammo MVV (maximum voluntary ventilation) Extremity (non joint) Specify: Methacholine Challenge Breast US if indicated Head/Brain PI Max/PE Max (also called MIP/MEP) Image Guided Asp./Biopsy if indicated Hip R L BIL Other – Specify: Knee R L BIL Breast MRI if indicated EMG Ductogram if indicated Pelvis EMG/NCS Lower Upper R L BIL Stereotactic Biopsy R L BIL NEURODIAGNOSTICS Shoulder R L BIL Needle Localization R L BIL AEEG – Ambulatory EEG Soft Tissue Neck US Guided Breast R L BIL Evoked Potential Auditory Biopsy Spine: Cervical Thoracic Lumbar Evoked Potential Visual Dexa Bone Density Evoked Potential Somatosensory Upper Ext Wrist R L BIL Other – Specify: Evoked Potential Somatosensory Lower Ext MR Angiography Specify: Routine EEG *Other – Specify:

Scheduled Date Time Comments N-C-PCP04514-12/20 • PH-57