Please select if you have a location preference: THIS PHYSICIAN ORDER MUST BE PRESENTED AT THE TIME OF SERVICE The Miriam Hospital Miriam Diagnostic Imaging Center (195 Collyer St) Rhode Island Hospital Medical Office Center Building (MOC) Please contact patient to make appointment Yes No STAT ROUTINE
First Name: ______Last Name: ______
DOB:______Phone: ______Insurance Plan /Plan #:: ______
ICD 10 Codes (REQUIRED): ______
Signs/Symptoms /Reasons for Exam (REQUIRED): ______
Ordering Provider (printed): ______Office Phone: ______
Physician Signature: ** ______Date: ______**MUST BE ORIGINAL SIGNATURE ; STAMPED SIGNATURES NOT ACCEPTED CT SCAN CONTRAST CT CHEST CT ABDOMEN & PELVIS CT EXTREMITIES RIGHT LEFT IV Contrast No IV Contrast Chest Abdomen & Pelvis Wrist C Oral Contrast Per Radiologist High Resolution Chest Renal/Ureter Stone Elbow T CT BRAIN / HEAD Sternum/Sternoclavicular joints Hematuria Shoulder Brain Temporal Bone Chest aortic dissection CT ABDOMEN ONLY Hips Mastoid Pulmonary embolus Abdomen ONLY (no pelvis) Femur S Gamma Knife Chest CTA M2S Study Liver Adrenal Knee Brain CTA CT SPINE Pancreas Kidney Tibia/Fibula C CT FACE Cervical Spine Renal CTA Ankle A Sinus Orbits Thoracic Spine Abdomen CTA M2S Study Foot /Calcaneous Face Sialogram Lumbar Spine CT PELVIS ONLY ______Arthrogram: ______N CT NECK Post Myelogram ______spine Pelvis ONLY (no abdomen) Lower Extremity “Run-Off” CTA Neck Neck CTA SPECIALTY EXAMS Acetabulum/hips Levels: ______Cervical Spine – Levels ______CT Virtual Colonoscopy Sacrum/Coccyx Upper Extremity CTA CT Enterography Pelvis CTA M2S Study Other______EKG Gated Coronary CTA Pulmonary Vein Map
MRI MRI CONTRAST With & Without Without NEURO MR MUSCULO/SKELETAL MRI BODY MR SPINE Brain: ______SIDE: RIGHT LEFT Chest: ______Adrenals Cervical Region of interest: ______Shoulder Hip Liver: ______Kidneys Thoracic Spectroscopy Humerus Thigh MRCP/Pancreas Lumbar Functional Brain: ______Elbow Knee Abdomen: ______Entire Spine (C, T, & L spine) M Soft Tissue Neck: ______Forearm Lower Leg Pelvis: ______Brachial Plexus (MRI Chest study) MR Angiography Head Wrist Ankle MR Enterography (Abdomen+Pelvis Study) RIGHT LEFT R Venous Flow Hand Foot MRA BODY Arterial Flow ______Fingers MRA Chest: ______MRA Spine: ______I MRA Neck: ______Toes MRA Abdomen: ______Dissection Arthrogram ______MRA Pelvis: ______Atherosclerosis upper lower MRA Peripheral: ______*MRI CARDIAC-Use detailed form *MRI BREAST- Use detailed form MRA Extremity Please specify: ______*To request MRI Cardiac or MRI Breast forms please contact [email protected] with your request **If patient has a pacemaker or is Pregnant please contact MRI and speak with an attending Radiologist at 401-444-4881 Will patient require YES NO If yes, please fill out sedation form anesthesia? If patient has any of the following conditions, the patient will need a creatinine level drawn within 6 weeks of appointment. YES NO Over 60 years old YES NO Hypertension or taking medication for high blood pressure YES NO Renal Disease or transplant YES NO Diabetes YES NO Dialysis Creatinine Level within six weeks: ______Date of labs: ______eGFR (if <60): ______
RVSD 07/16 Patient Referral Form for Exams Phone: 401-444-7770 Fax: 401-444-7779 Email:[email protected] Please select if you have a location preference: THIS PHYSICIAN ORDER MUST BE PRESENTED AT THE TIME OF SERVICE The Miriam Hospital Miriam Diagnostic Imaging Center (195 Collyer St) Rhode Island Hospital Medical Office Center Building (MOC) Anne Pappas Center
Please contact patient to make appointment Yes No STAT ROUTINE
First Name: ______Last Name: ______
DOB:______Phone: ______Insurance Plan /Plan #:: ______
ICD 10 Codes (REQUIRED): ______
Signs/Symptoms /Reasons for Exam (REQUIRED): ______
Ordering Provider (printed): ______Office Phone: ______
Physician Signature: ** ______Date: ______**MUST BE ORIGINAL SIGNATURE ; STAMPED SIGNATURES NOT ACCEPTED ULTRASOUND ABDOMEN MALE PELVIS U Abdomen Complete (with vascular evaluation if needed) Testes (with blood flow Doppler evaluation if needed) Right Upper Quadrant Limited (with vascular evaluation if needed) Pelvis L CCK GB ejection fraction (RIH MOC ONLY) Prostate Renal with bladder (Post Void Residual) Prostate Bx T Renal with blood flow (resistive index) Doppler Pelvis – Post Void Residual only Renal - no vascular evaluation FEMALE PELVIS R Renal-Complete Doppler- RAS Transabdominal (with Transvaginal and/or Doppler eval. if needed) A Renal Transplant with Doppler evaluation Transvaginal (with Doppler evaluation if needed) Abdominal Aorta Follow up Abdominal Aorta Screening OB (less than 14 weeks) LMP ______S Liver with Doppler and Elastography OB (greater than 14 weeks) EDD______SMALL PARTS OB limited ______O Thyroid/Parathyroid OB other______U Palpable Lump (designated area to be evaluated)______Pelvis for Post Void Residual only Thyroid Biopsy Location______/or Determined by Radiologist VASCULAR-VENOUS N Breast RIGHT LEFT Lower Extremity – Unilateral RIGHT LEFT CHEST Lower Extremity – Bilateral D Chest Upper Extremity – Unilateral RIGHT LEFT OTHER (please specify) Upper Extremity – Bilateral Non-Vascular Extremity Other______VASCULAR-ARTERIAL Groin/Hernia ______Carotid Palpable Lump (desinated area to be evaluated)______Lower Extremity Arterial-Unilateral RIGHT LEFT MSK (please specify)______Lower Extremity Arterial –Bilateral FOR ABI’s CONTACT VIR @ 444-5194 GENERAL RADIOLOGY R EXTREMITY RIGHT LEFT Chest specify:______GI/FLUORO STUDIES Hand Pelvis Ribs RIGHT LEFT Barium Enema A Wrist Hip Foreign Body with air without air Forearm Femur Abdomen Barium Swallow D Elbow Knee Flat & Upright Small Bowel I Humerus Tibia/Fibula Kidney/Ureters/Bladder(KUB) Upper GI Shoulder Ankle Spine Defecogram O Clavicle Foot Cervical GU STUDIES Scapula Lumbar VCUG L Thoracic Retrograde urethrogram Thoracolumbar Urethrogram O BONE DENSITY DEXA HT:______WT:______Scoliosis Cystogram G Sinus Loopogram Bone Survey Y ORDER COMMENTS: ______Metastatic Bone Series Other: ______Scanogram ______Shunt Series BREAST IMAGING Date of last exam:______Screening Mammography RIGHT LEFT Mammography Diagnostic Bilateral Ultrasound Guided Biopsy PRN Ultrasound Cyst Aspiration Mammography Diagnostic Unilateral Fine Needle Aspiration RIGHT LEFT Stereotactic Biopsy PRN Ultrasound Needle Localization Limited Breast Ultrasound for Clinical Findings Consultation w/imaging or biopsy prn RIGHT LEFT
Galactogram Location: ______Complete Breast Ultrasound for screening dense breast
RVSD 07/16 Patient Referral Form for Exams Phone: 401-444-7770 Fax: 401-444-7779 Email:[email protected]