VCU Health Outpatient Imaging Request

Patient Name: ______Date of Birth: ______Today’s Date: ______One Convenient Number! Patient Phone #: ______*Clinical History: ______Call to schedule your appointment Diagnosis Code(s): ______804.628.3580 Referring Physician: ______Physician Signature: ______Monday – Friday Phone #: ______VCU Health Radiology Physicians are authorized and have my permission to add or delete any additional imaging procedures required to appropriately diagnose the patient I am referring. 8 a.m. – 6 p.m. Disclaimer/Authorization  YES  NO

Date: ______DIAGNOSTIC X-RAY – NO APPOINTMENT NECESSARY ABDOMEN SKELETAL SPINE Time: ______ KUB  Ankle  L  R  Limited  Standing  Pelvis  L  R  Limited  Standing  Cervical  Complete  Flat, Erect and PA Chest  Bone Age  Shoulder  L  R  AP and Lateral Only Please arrive 30 minutes prior to your  Decubitus  L  R  Clavicle  L  R  Tib/Fib  L  R  Flexion and Extension appointment time and bring the CHEST/RIBS/SINUS  Elbow  L  R  Limited  Toes  L  R  Lumbar  Complete  Wrist  L  R  Limited  AP and Lateral Only following information with you:  PA Chest  Facial Bones  L  R  Limited  PA and LAT Chest  Femur  L  R  Flexion and Extension  Ribs unilateral  L  R  Fingers  L  R  Sacrum/Coccyx • This form signed by your referring  Ribs unilateral w/ PA chest  L  R  Foot  L  R  Limited  Standing  Scoliosis Survey physician  Ribs bilateral w/ PA chest  Forearm  L  R  SI joints  L  R  Limited  Standing  Decubitus Chest  L  R  Hand  L  R  Limited  Thoracic • Insurance card Sinuses  Complete  Limited  Hip  L  R • Photo ID (i.e. license, passport)  Waters View only  Humerus  L  R OTHER (specify): ______ Knee  L  R  Limited  Standing • Any previous images and reports Skull  Complete  Limited performed at a non-VCU Health EXAMINATIONS REQUIRING A SCHEDULED APPOINTMENT TIME facility including X-rays, DEXAs, CT SCAN MRI PET mammograms, MRIs, CT scans,  w/ IV contrast  w/o IV contrast  w/o Gadolinium  w/wo Gadolinium Organ: ______ Tumor Head to Toe  w/wo IV contrast  w/ Oral contrast  Abdomen  Tumor Skull Base to Mid-Thigh and ultrasounds, if available  Abdomen  Pelvis  Cardiac Metabolism  Abdomen/Pelvis  Enterography  Brain Dementia/Alzheimer’s  Chest  Chest (non-cardiac) Facility Preference:  CT Urogram (no oral contrast needed)  Breast ULTRASOUND  Head  Brain  Neck  Soft Tissue Neck  Head  Abdominal  Abd. RUQ  Abd. Hernia/Appy  Spine:  Cervical  Thoracic  Lumbar ______ Lower Ext. (Area/Joint) ______ L  R  Pelvic with TV and/or Doppler PRN  Upper Ext (Area/Joint) ______ L  R  Neck – Soft Tissue  Bladder Downtown Campus, Stony Point,  Lower Ext (Area/Joint) ______ L  R  Pelvis  Renal/Retroperitoneal  MRA/MRV Location: ______New Kent, Short Pump Pavilion,  Renal Stone Protocol  Obstetrical  under 14 weeks  over 14 weeks  Other: ______Baird Vascular Institute,  Sinuses  Biophysical Profile  Spine:  Cervical  Lumbar  Thoracic  Breast  L  R  Bilat Adult Outpatient Pavilion  Upper Ext. (Area/Joint) ______ L  R NUCLEAR MEDICINE EXAMS  Breast Biopsy ____ o’clock  Lung Cancer Screening  Nonvascular EXT  Upper  Lower  L  R  Bone Imaging When faxing this form, please include a  Scrotal/Testicular with Doppler PRN  3Phase Multi  SPECT  Whole Body  Thyroid  FNA copy of patient’s insurance card. CTA:  Stress Thallium (treadmill or dobutamine) or lexiscan  Soft Tissue body part ______ Abdominal Aorta with Run-off  MUGA Scan  Hysterosonogram/Pelvis as needed  Cardiac (CTA)  Calcium Score Only  EKG Treadmill Stress  Venous Dop. Ext Fax: 804.628.3593  CTA/Location: ______ Gallium Scan  Upper  Lower  L  R  Bilat  Other: ______ Gastric Emptying  Solid  Liquid  Carotid Doppler  L  R  Bilat  Check here if you’d like the  Gastric Reflux (Milk Scan)  Other: ______images sent via Life Image FLUORO/IVP/HSG  HIDA Scan  w/CCK  Thyroid  Thyroid & Uptake  Upper GI Imaging request forms for:  UGI/Small Bowel Series  Thyroid Whole Body  Small Bowel Series  Iodine Therapy ______MAMMOGRAPHY, Medical Records Copy  Esophagram/Barium Swallow  VCUG  Renal Scan  w/lasix  w/captopril HM-R-1175 (rev. 05-21)  Video Swallow/CINE INTERVENTIONAL RADIOLOGY,  Barium Enema  Renal Flow w______ Bowel Transit Study  Liver SPECT (Hemangioma Study) NONVASCULAR INTERVENTIONAL RADIOLOGY,  IVP  Cisternogram  VCUG  DMSA Scan and MUSCULOSKELETAL PROCEDURES, please visit  Other: ______ WBC Labeled Scan (Indium)  VQ Scan https://www.vcuhealth.org/services/radiology  Other: ______http://www.vcuhealth.org/services/radiology ONE CONVENIENT NUMBER FOR SCHEDULING! CALL 804.628.3580