EAST HIXSON DOWNTOWN OOLTEWAH DALTON CLEVELAND 1710 GUNBARREL RD. 2070 HAMILL RD. 440 N. HOLTZCLAW AVE. 9368 BRADMORE LANE 1502 N. THORNTON AVE. 2253 CHAMBLISS AVE. N.W. CHATTANOOGA, TN 37421 HIXSON, TN 37343 CHATTANOOGA, TN 37404 OOLTEWAH, TN 37363 DALTON, GA 30720 SUITE 102 CLEVELAND, TN 37311 Phone: 423.553.1234 Fax: 423.553.1235 Patient’s Name ______Date of Birth ______Appointment Date ______Time ______Patient Email ______Procedure Requested (If not listed below) ______Diagnosis ______Special Instructions ______Ordering Physician ______Physician’s Signature______Please Print Report: q ROUTINE q URGENT q STAT Call STAT report to ______at phone # ______at FAX# ______Perform ASAP Call Results Name After hours/direct phone number Critical result findings will be called to referring providers per CI policy. PET/CT SCAN ULTRASOUND q Brain q Body q ABI MRI q Thyroid Contrast at Radiologist discretion unless otherwise indicated q Retroperitoneal (to include , pancreas, kidneys, bladder) q Brain w/3D Reconstruction q Testicular W/ Color Doppler q MRA (q Head q Carotids) q Carotid Special Instructions: ______q Lower or upper extremity venous ( q Right q Left ) q Breast q Renal Artery Stenosis w/ Color Doppler q Pelvis FLUOROSCOPIC STUDIES q Cervical Spine q Thoracic Spine q Lumbar Spine q q MR Abdomen w/wo to include Esophagram q Abdomen Special Instructions: ______q Upper GI series q w/small bowel series q Shoulder (q Right q Left) q w/ q w/o arthrogram q Barium Swallow q w/speech pathologist q Extremity (q Right q Left) Body Part: ______q Lumbar Puncture CT SCAN q IVP/excretory urogram Contrast at Radiologist discretion unless otherwise indicated q Barium enema q w/air contrast q CT Enterography q HSG q Abdomen q w/pelvis q Lumbar Myelogram q Pelvis q Steroid Injection Specify location:______q Chest q Soft Tissue Neck q Bone scan q q q Sinus ( Screening Complete) q Whole Body q Three Phase q Add Spect q Facial Bones q Lung Scan q Temporal Bones q q Brain HIDA (Gallbladder/hepatobiliary) Special Instructions: ______q Thyroid Scan/uptake q CTA Body Part: ______q Renal Scan q Coronary CT (CCTA) q Myocardial Perfusion Rest/Stress (stress test) q Cervical Spine q Cardiac MUGA q Thoracic Spine q Gastric Emptying q Lumbar Spine q Octreoscan q Extremity Body Part: ______q Prostascint / BMD q Indium WBC q Indium WBC with Bone Scan q Screening q Diagnostic q RBC Liver q Bone Mineral Density q Liver/Spleen with Spect X-Ray q Parathyroid Scan with Spect Body Part______q Right q Left q MIBG Scan with Spect ULTRASOUND INTERVENTIONAL PROCEDURE q Breast ( q Right q Left q Bilateral) q Biopsy Part of body: ______q Abdomen (incl. liver, gallbladder, kidneys, aorta, spleen, pancreas) q Vascular Line Placement Type: ______q Pelvis q Transvaginal q Paracentesis q Thoracentesis q Ultrasound guided biopsy q Endo Venous Laser Treatment (EVLT) q Ultrasound guided aspiration q Office Visit with Dr. ______re: ______q Echocardiogram q OB Ultrasound OTHER q SHG q EKG q EEG q EMG 1710 Gunbarrel Road. • Phone: 423-553-1234 Bone Mineral Density (BMD) glucose that you will receive before your procedure. Your blood • Eat as you normally do on the day of your exam. glucose level must be less than 200 at the time of your scan. If • Do not take any calcium supplements for 24 hours before your you take insulin (injection or pill form), it must be taken at least exam. 4 hours before your scan. If your glucose levels are over 200, • If you have had a radioisotope injection, a barium study, or please contact us before coming in so that we can work with received oral or intravenous contrast material during a CT scan you and your physician to obtain a high-quality scan. or MRI, you must wait seven days before having a BMD. • If you need them, please bring along medications for pain, • Wear loose, comfortable clothing, such as a sweat suit or other anxiety, or claustrophobia. casual attire that does not have metal zippers or buttons. • Avoid strenuous exercise for 48 hours before your exam. Directions to East: From Chattanooga or Knoxville take CT (Computed ) • Please inform the technologist of any medications that you are East Brainerd Road East Exit #3A. Continue on East currently taking. Brainerd Road. Turn left on Gunbarrel Road, Chattanooga • Abdomen/Chest/Pelvis/Head with and without contrast: Nothing Imaging East is located on right. to eat or drink for four hours before exam. Nuclear Renal Scan • Angiogram: Nothing to eat or drink for four hours before exam. • Do not take any diuretics (water pills) the day of your exam. 2070 Hamill Road. • Phone: 423-553-1234 • Colonography: A bowel preparation to clean the colon before the • Drink at least 20 oz. of fluids up to 90 minutes before you arrive. test is required to ensure a successful exam. Our staff will give No food 2 hours before test. you precise instructions when your test is scheduled. Captopril Renal Scan Gastric Emptying Study • Do not take any blood pressure medications the day of your • Do not eat or drink anything for eight hours before the exam. exam. If you are taking a blood pressure medication known as • Do not take medicines beforehand unless directed by your an ACE Inhibitor it will be necessary to speak to your physician doctor. regarding alternative blood pressure medications to be taken • Do not take stomach medicine unless directed by your doctor. for 3 days prior to your exam. • Do not take any diuretics (water pills) the day of your exam. Hepatobiliary Scan (HIDA) • Drink 20 oz. of fluids 90 minutes before you arrive. • Do not eat or drink anything 4 to 6 hours before your exam. (Do Directions to Hixson: Take Hwy 153 to Hamill Road. not fast over 12 hours). Thyroid Scan and a Thyroid Uptake Turn beside CVS. Located 2/10 of a mile on right across • You should wait at least four weeks after having intravenous from the entrance to North Park Hospital. • Do not take any prescription pain medications 6 hours prior to your exam. iodinated contrast before having your thyroid scan and uptake. This includes contrasts (sometimes called x-ray dye) that are DOWNTOWN Interventional 440 N. Holtzclaw Ave. • Phone: 423-553-1234 used for catheterizations, CT scans, kidney x-rays, or You may be seen in our interventional radiology clinic to speak to intravenous urograms (IVPs), and angiograms. the nurse or interventional radiologist to discuss the procedure and Train Tracks Cleveland Ave. • You will need to discontinue your thyroid medication for a have pre-procedural imaging. While many procedures are done on certain period of time ranging from several days to a month, an outpatient basis, some of the more extensive procedures will E 3rd St. N Holtzclaw Ave. Cumberland St. depending on which medication you are taking. Exactly when be performed in a hospital setting. Please give your interventional you should stop taking your medication is usually established E 3rd St. radiologist a list of any medications you take when you come in when you schedule your exam. If you do not find out then, for your procedure. The radiologist will work with your primary

N Highland Park Ave. please call and speak to our staff to find out when you should E 3rd St. physician to help determine the best treatment plan. stop taking the medication. CHATTANOOGA IMAGING Mammography 440 N. Holtzclaw Ave. Ultrasound N Holtzclaw Ave. • On the day of your exam, you should not use deodorant or • Abdominal ultrasound: Nothing to eat or drink six hours prior to Directions to Chattanooga: From US-27, take exit powder, as some of the ingredients these contain may result in a 1C to merge onto W 4th Street toward Downtown/ exam. State Route 58N for 1.1 miles. Take a slight right onto E false-positive reading on your mammogram. • Obstetrical ultrasound/Retroperitoneal ultrasound (kidneys, 3rd Street for 1.1 miles and turn left onto N. Holtzclaw. • Tell your physician and the technologist if you think you may be Chattanooga Imaging is located on the right. bladder): You will be asked to drink 24 oz. of water one hour pregnant or if you are breast feeding. CLEVELAND before exam time and to hold your bladder until the exam is 2253 Chambliss Ave., Ste. 102 • Phone: 423-553-1234 • If your last mammogram was performed at another facility, complete. please ask for those films be sent to our facility so that we can • Pelvic ultrasound: You will be asked to drink 32 oz. of water 30 Ben Dr. NW compare them to your new images. minutes before exam time and to hold your bladder until the SKYRIDGE 24th St. NW • Wear comfortable clothing with separate top and bottom. This will MEDICAL exam is complete. CENTER Harris Circle NW eliminate the need to remove your entire outfit for the procedure. Oakland Dr. NW • : Wear a two-piece outfit. No other preparation MRI Abdomen is needed. CLEVELAND IMAGING Nothing to eat or drink four hours prior to exam. 2253 Chambliss Ave. • Renal artery stenosis ultrasound: You will be given anti-gas pills 23rd St. NW 23rd St. NW

N. OCOEE STREET MRI 21st St. NW to take the evening before and the morning of your exam. You

22nd St. NW No special preparation is required before your MRI exam. Metal will be asked to drink 24 oz. of water 30 minutes before exam Chambliss Ave. objects, such as jewelry, hairpins, and car keys, are not allowed in time, and you can empty your bladder as needed. Directions to Cleveland Imaging: From I-75, take the scan room, you will be asked to leave any such items in a safe • Interventional ultrasound: Preparation will depend on the exit 25. From exit ramp, turn onto 25th Street towards Cleveland. Continue for 1.4 miles. Turn right onto place before beginning your MRI. We will also ask you whether you procedure being performed and will be explained to you when Chambliss Avenue. The Bradley Professional building is have any metal implants or a pacemaker, since some patients with your exam is scheduled. located .2 miles on the right. these devices may not be able to have an MRI. Upper GI OOLTEWAH Myelogram 9368 Bradmore Ln. • Phone: 423-553-1234 • Nothing to eat or drink after midnight the night before your • If you are taking any type of blood thinners, you must not take exam. them for three days before your exam — but be sure to speak Bradmore Ln. • Do not take medications on the morning of your exam. You may with your physician before stopping any medications. bring any required medications with you to take after the exam. • We recommend that you eat a light breakfast, as you will be lying Arbury Way Arthrogram Ooltewah Georgetown Rd. face down during the procedure. CHATTANOOGA IMAGING • Wear comfortable, loose-fitting clothing. Because metal can 9368 Bradmore Ln. • If you are taking any type of antidepressant or antipsychotic Chesterton Way Hwy 64 affect the image, please do not wear anything with metal snaps medication, you must not take it on the day of the exam and for or zippers. 24 hours after the exam. • Before your exam you will be asked to remove items such as • You must bring a driver to take you home after the exam. Hwy 64 eyeglasses, hearing aids, hairpins, and jewelry. Myocardial Perfusion Scan • Let us know if you think you may be pregnant. Directions to Chattanooga Imaging: From I-75, take • No food 4 hours prior. Water is OK. Intravenous Urogram (IVP) exit 11 toward Ooltewah/Collegedale. Continue on • Do not take any medications on the morning of the exam unless US-11/US-64. Turn left onto Arbury Way. Turn left onto • Pick up a prep kit from our front desk and follow the instructions Bradmore Ln. Chattanooga Imaging is located on the left. approved in advance. on the back of the box. • Do not drink or eat any caffeinated products for 24 hours prior to DALTON Hysterosalpingiogram the exam. 1502 N. Thornton Ave. • Phone: 423-553-1234 • Eat something light the night before your exam, like soup or • Bring with you a list of your current medications. salad. • Wear loose, comfortable clothing and shoes suitable for walking • Take a laxative the night before your exam. on a treadmill. • Do not eat or drink anything on the morning of your exam. Cleo Way PET/CT (Positron Emission Tomography) Synovus • Urinate right before the exam. Bank • Do not eat or drink anything for at least six hours before arriving Cherokee Sibley Medical Heart • Let us know if you are allergic to contrast dye or seafood. Center for your PET/CT scan. If you need to take medications, you may

Valurite Discount N. Thornton Ave. Barium Enema / Gallbaldder Pharmacy take them with a small amount of water. If any of your medications • Pick up a prep kit from our front desk and follow the instructions CHATTANOOGA IMAGING need to be taken with food, you may eat a few saltine crackers. 1502 N. Thornton Ave. • If you have diabetes, you will need to regulate your blood sugar, on the back of the box. since the glucose in your blood will compete with the radioactive • Nothing to eat or drink after midnight the night before your Directions to Chattanooga Imaging: From I-75 S, exam. take exit 336 to US-41 S/US-76 E to N. Thornton Ave. Turn right onto N.Thornton Ave. Chattanooga Imaging is located on the left.