Imaging Subspecialists of North Jersey, LLC Bhanu Aluri, MD Edward Millman, MD Romulo H. Balthazar Prashant Parashurama, MD Patrick J. Conte, MD Orestes Sanchez, MD Madelyn Dano , MD Robin Frank-Gerzberg, MD Frank R. Yuppa, MD Steven Kwon, MD OneOne Bay Ba Avenuey Avenue • Montclair • Mon NtclairJ, 07042 NJ, 07042 Chairman of Radiology Waren Frietag Central Scheduling: 973-873-7787 or 877-523-7787; Fax 973-680-7946 Medical Director Kalavathy Balakumar (973) 429-6106 - MRI (973) 429-6110 - Nuclear/PET (973) 429-6111 Marianne Centann Radiology

Today’s Date: Patient Name:

Clinical Signs/Symptoms: ICD9 Code: AAuthorization/uthorized/PreP-rcee-rCertt Number Number ( * R(ifE Qavailable)UIRED P:rior______to Appointment): ______Referring Physician Name: Phone:

Referring Physician Signature: Fax:

Wet Reading Patient to Return with Images LAB - BUN Creatinine (For IV contrast if no recent labs) MRI GENERAL RADIOGRAPHY * CT (DUAL SOURCE MULTI-SLICE) Head/Brain Chest Esophagram IVP Head/Brain Chest IAC’s Abdomen UGI Series KUB Sinuses Abdomen Nasopharynx Pelvis Small Bowel Series Obstructive Series Facial Pelvis Orbits Brachial Plexus Upper GI with small bowel Neck (Soft Tissue) Orbits Cervical Spine Pituitary Neck (Soft Tissue) Barium Enema Chest Mandible Thoracic Spine Perfusion Cervical Spine VCUG Skeletal Survey Neck (Soft Tissue) Lumbar Spine TMJ Thoracic Spine Skull Series Cervical Spine NON CONTRAST CONTRAST MRI Spectroscopy Lumbar Spine Nasal Bones Thoracic Spine Oral Contrast with IV contrast MRCP Fetal MRI Sinuses Lumbar Spine with/without IV Shoulder Facial Bones Scoliosis Series Other (Specify) Elbow RT LT Orbits Bone Age Wrist RT LT Mandible Hand RT LT Ribs RT LT Hip RT LT Shoulder RT LT * CT ANGIOGRAPHY (CTA) Knee RT LT Humerus RT LT (Specify) Ankle RT LT Elbow RT LT Foot RT LT Forearm RT LT CARDIAC CT NON CONTRAST RT LT Wrist RT LT * WITH/WITHOUT CONTRAST Hand Calcium Scoring Pelvis RT LT Coronary CTA Hip RT LT Other Other (Specify) Femur RT LT Knee RT LT CT ARTHROGRAM Tibia/Fibula RT LT * (Specify Joint) RT LT Ankle RT LT MRI ARTHROGRAM * Foot (Specify Joint) RT LT Other (Specify) ULTRASOUND/SONOGRAM

Thyroid Pelvic * MRI ANGIOGRAPHY (MRA) Abdomen (Transvaginal if indicated) (Gallbladder, Liver, Pancreas) Specify Pelvic OB BONE DENSITOMETRY/DEXA Retroperitoneum Testicular Kidneys Pediatric Cranial Call 973-429-6110 to schedule Urinary Bladder Pediatric Spine BREAST IMAGING & BIOPSY NUCLEAR MEDICINE Aorta Pediatric Hip With Flow Other (Specify) * MRI BREAST RT LT BIL Bone Scan Thyroid NON CONTRAST Hepatobiliary CONTRAST SONOHYSTEROGRAM GB with CCK Call 973-429-6110 to schedule Gastric Empty MAMMOGRAPHY Renal Transplant Vasotec Lasix COLOR DOPPLER STUDIES Screening RT LT Other (Specify) Carotid Diagnostic Renal duplex Unilateral Lower Extremity Arterial RT LT Breast Ultrasound if Indicated PET — Call: 973-429-6111 to schedule Upper Extremity Arterial RT LT Lower Extremity Venous RT LT ULTRASOUND/SONOGRAM NUCLEAR CARDIOLOGY Upper Extremity Venous RT LT Breast RT LT BIL Nuclear Stress Test Treadmill Adenoscan Other (Specify) Breast Ultrasound MUGA Guided Biopsy RT LT BIL Breast Ultrasound Aspiration RT LT BIL Breast Ultrasound Right Breast Left Breast Fine Needle Aspiration RT LT BIL Please APPOINTMENT DATE: ______Indicate STEREOTACTIC BREAST NEEDLE BIOPSY Area of TIME: ______AM/PM Right Breast Concern Kindly Provide 24 Hours Notice of Cancellation Left Breast

SEE REVERSE FOR DIRECTION/INSTRUCTIONS HBG MSH70104 (3/15/13) 1.2 Directions

Parkway Traveling NORTH: Route 80 Traveling WEST: Exit at 148 Exit at Garden State Parkway (Saddle Brook) and exit. After toll booth, keep left for a short distance, take the Parkway south. Exit at 151 Watchung Avenue (Montclair/Nutley). Follow directions from immediately make “U” turn under the Parkway Parkway SOUTH. where indicated. Keep to far right and make a right From Route 280: Travel Route 280 east to the Garden State Parkway northbound. Exit Parkway at 148. Avenue to Bay Avenue and make a left turn. Follow directions from Parkway NORTH. Proceed on Bay for two short blocks, hospital is on the left. Proceed past front entrance and make a From Route 3: left at next comer, Walnut Crescent. Parking garage Exit at Grove Street, follow signs to Montclair. is one block on your right. Drive south on Grove Street (approximately 5 miles) until you reach a Railroad Crossing. The next Parkway Traveling SOUTH: Exit at 151 Watchung Avenue (Montclair/Nutley), is Claremont Avenue. Turn left onto Claremont toll booth at exit. After toll, turn right onto Watchung Avenue and follow to Walnut Crescent (2 blocks). Avenue and go about 1 mile to Ridgewood Avenue Parking garage is one block on your right. DETAIL MAP right turn on Bay Avenue and proceed two short blocks, hospital is on the left. Proceed past front entrance and make a left at next comer, Walnut Crescent. Parking garage is one block on your right. Route 80 Traveling EAST: Exit at the sign marked Route 46 and proceed east on Route 46 about 3 miles to Route 3 exit. Take Route 3 about one-half mile to Grove Street exit and bear right at top of ramp. Drive south on Grove Street (approximately 5 miles) until you

you cross over the railroad tracks is Claremont Avenue. Turn left onto Claremont Avenue. Follow Claremont until you reach a fork in the road and bear right onto Walnut Crescent. Parking garage is one block on your right. X - Free Parking

Preparing for Your Examination Please call the Radiology Department for pediatric instructions at (973) 429-6100.

MRI (Magnetic Resonance Imaging) IVP (Intravenous Pyelogram) MRCP Prep-NPO no food or drink 4 Hours Prior. Call us if you are Take 2 Dulcolax tablets at 4:00 p.m. the day before exam. Nothing to eat pregnant or have a cardiac pacemaker, implanted cardiac de brilla- or drink 4 hours before exam. tor, aneurysm clips, cochlear ear implants, heart stents, retinal diabetes and any medications taken. implants, implantable insulin pumps, any recent major surgeries, neurostimulators, occular foreign bodies, or patches. If you are claustrophobic, please contact our oce for instructions. Music is Mammography available during the examination. If you prefer, bring your own tape or CD for exam. perfume or powder underarm or breasts the day of exam. Bring previous mammograms and reports the day of exam for comparison. CT (Dual Source Multi-Slice)

Abdomen and Pelvis : Pick up oral contrast the day before exam. Nothing to eat or drink 4 hours before exam time. Drink 1 bottle of Ultrasound oral contrast 2 hours before exam. Drink second bottle 1 hour before Abdomen (Gallbladder): Nothing to eat or drink 6-8 hours before exam. exam. Pelvis: Drink 40 oz. of water 1 hour before the exam. Do not empty bladder. Upper GI Series/Small Bowel Pregnancy 1-6 months: Drink 32 oz. of water 1 hour before exam. Nothing to eat or drink 8 hours before exam. Do not empty bladder. Pregnancy 1-9 months: Drink 8 oz. of water 1 hour before exam. Barium Enema Do not empty bladder. Contact Radiology Dept. for Prep 973-429-6100

* Please bring previous images & reports the day of exam for comparison for outpatients.

HBG MSH70104 (3/15/13) 2.2