Today’s Date: / / PATIENT: Name:

DOB: / / Phone: SSN (last four digits): 1200 Waters Place Suite M108, REFERRING PHYSICIAN: Bronx, N.Y. 10461 Ph. 718.931.5620 Fax. 718.824.0706 Ordered by: Phone/Fax: www.udmi.net

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Diagnostic Notes:

MAGNETIC RESONANCE IMAGING (MRI) OPEN HIGH FIELD 3T Non Contrast Pre & Post Contrast MRA () Brain Prostate w/Contrast Abdomen Knee MR Arthrogram Aorta Extremity-Upper Int. Aud. Canal C Spine for iron quantification Shoulder Hip Brain Extremity-Lower Pituitary T Spine for fat quantification Ankle Foot Chest Carotid/Neck Orbits L Spine Pelvis Wrist Elbow Renal MRV-Brain TM Joints Soft Tissue Neck MR Cholangiogram Hand Other L R Abd MRV-Extremity L R Scrotal w/ Contrast Breast Chest 64 Slice CT SCAN W/ Contrast W/O Contrast BOTH CTA (Angiography) PAIN MANAGEMENT Brain Chest (Lung) Genitourinary Lung (screen) Abd/Pel Consultation Joint Inject Sinus High Res Lung C Spine CT Biopsy Pulmonary Artery Epidural Steroid Soft Tissue Neck Abdomen T Spine Cardiac Calcium Scoring Aorta Nerve Block Hydrogel Temporal Bone Pelvis L Spine Virtual Colonoscopy Carotid Coronary Facet Block Facial / Orbit Abdomen/Pelvis CT Myelogram Enterography-Sml Bowel Brain Artery (CCTA) Other______Orthopedic Imaging Virtual Bronchoscopy CT Joint Arthrogram Extremity ULTRASOUND DIAGNOSTIC X-RAY NUCLEAR MEDICINE Abdomen Chest KUB Bone Scan Abd for abnormal LFT w/ VVD Sinus C Spine Bone SPECT MAKE AN Kidneys Neck T Spine 3 Phase Bone Scan Bladder/Pelvis Skull L Spine APPOINTMENT Aorta Abdomen Bone Age Hemangioma Liver Scan Scrotum Hepatobiliary (HIDA) with Pelvis L R Prostate (Transrectal) GB Study Shoulder Thyroid Para Thy GB Function CCK Humerous Liver Spleen Scan LIVE CHAT! Soft Tissue ______Elbow Extremity Lung Scan (V/Q) Forearm Carotid-(Color Doppler) Renal Scan Wrist Transcranial Function Hand Obstruction (LASIX) Aorta-(Color Doppler) Hip Hypertension Peripheral Extremities Femur Thyroid Scan/Sono-Uptake L R Knee I-131 Hyperthyroid Therapy Just visit www.udmi.net Arterial Tib-Fib Parathyroid Scan For full instructions, see the back of this referral w/Segmental ABI Ankle Venous (DVT) Gastric Emptying Foot WOMANS IMAGING Venous (Reflux) L R Other______Mammogram (Screening) NUC-CARDIOLOGY Abdomen w/Fibrosis/Scan Mammogram (Diagnostic) Cardiac SPECT Stress/Gated (Hepatitis) GI Series (W/Esophogram) Breast Ultrasound Treadmill Small Bowel (W/limited GI) Breast Biopsy/Aspiration Dipyridamole 2D, M-Mode W/Color Dop- Barium Enema Breast MRI Non Contrast W & W/O MUGA (LV Function) (EF) pler X-Ray Hysterosalpingogram Pelvic MRI Non Contrast W & W/O Musculoskeletal Arthrogram PET/CT Transvaginal Sono Pelvic Sono Site: Tel: 718.931.2300 OB Sono DEXA Bone Density

FDG OB BioPhysical Profile

Special Instructions: Whole Body Sono Hysterogram Brain X-Ray Hysterosalpingogram NAF (Sodium Fluoride) Biopsy / Interventional Procedures F18 Bone PET Thyroid ______Drainage ______Diagnostic Notes: Breast______Bone______Lung______Port______Liver______Catheter______Lymph Node______Other______Mass______PICC Line______Visit us online! PAY YOUR BILL PATIENT PORTAL

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1. Go to www.udmi.net 2. At the top of the webpage, click "PATIENT PORTAL" **IMPORTANT: Make sure all of the 3. Select "Register for Access" information you provide (name, date of birth and email) matches what you have 4. Fill in all fields and click “Register for Access” on file with us. Any items that do not 5. You will receive an email to the address you provided in your match may prevent you from accessing registration to activate your account. Open that email and hit your account. If you're not sure, get in "Activate Account". You will not be able to log in without completing touch with us to confirm this step 6. Once your account is activated, you may use your login credentials to access your personal health information