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Procedure Request Form 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 aorta, 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 Elastography Esophagram q Abdomen Special Instructions: ________________________ q Upper GI series q w/small bowel series q Shoulder (q Right q Left) q w/ arthrogram 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 NUCLEAR MEDICINE 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 Angiography (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 MAMMOGRAPHY / 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 Tomography) • 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 Radiology 440 N. Holtzclaw Ave. • Phone: 423-553-1234 used for heart 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 • Breast ultrasound: 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.
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