Scheduled Patients Consultation: Authorization #: Adult & Pediatric Fluoroscopy, Mammography Radiology Fax to: Patient Name:

Med. Rec. #: Date of Birth: ___/___/___ Sex: Male Female

TO BE COMPLETED BY PHYSICIAN TO BE COMPLETED BY CLERK

Specific question(s) to be answered by this study: Ordering Physician: Dr. #: Beeper #: Attending Physician: Signs, Symptoms, Relevant Diagnosis: Service: Clinic: Today’s Date: Exam Date: Does patient have HMO? Yes No Allergy to contrast? Yes No Is procedure approved? Yes No Patient pregnant? Yes No Studies Not Listed:

Physician Signature:

Will patient return to clinic? Read and return GASTROINTESTINAL GENITOURINARY (cont’d.) MAMMOGRAPHY Barium Enema Intravenous Pyelogram (VP) Breast Ultrasound Barium Enema w/Air IVP w/Tomography Breast Ultrasound – Limited Enema with AIR only IVP Abbreviated Mammography Screening Chest w/Fluoroscopy Retrograde Pyelogram Mammography Bilateral w/implants Chest Fluoroscopy Loopogram/Pouchogram Mammography Bilateral Cholangiogram – T-tube Retro Urethrogram Mammography Bilateral - Limited Cine speech With additional views and/or Defocography ARTHROGRAM ultrasound as needed. Enteroclysis Arthrogram Ankle Mammography Unilat w/implants - Left ERCP Arthrogram Elbow Mammography Unilat w/implants – Right Esophogram Arthrogram Hip Mammography Unilateral – Left Esophogram w/Hypopharynx Arthrogram Knee Mammography Unilateral – Right Fluoroscopy Arthrogram Shoulder Mammography Ductogram Flatula Tract/Sinogram Arthrogram Wrist Breast Abscess Drainage – Left Foreign Body Removal Breast Abscess Drainage – Right GI Series MYELOGRAPHY Breast Biopsy Stereotactic - Left Gi Series w/Small Bowel Series Cervical via C1-2 Puncture Breast Biopsy Stereotactic – Right GI Tube Placement Cervical via Lumbar Puncture Breast Core Biopsy – Left Gi Tube Reposition Thoracic via Lumbar Puncture Breast Core Biopsy – Right Intussception Enema Lumbar via Lumbar Puncture Breast Core Biopsy – US Laryngiogram Total Axis via Lumbar Puncture Breast Cyst Aspiration – Left Rehab Barium Swallow C1-2 Puncture – Diagnostic Breast Cyst Aspiration – Right Small Bowel Series Only Lumbar Puncture – Diagnostic Breast Cyst Aspiration – US Water Soluble Enema Lumbar Puncture – Therapeutic Breast Lesion Localization – Left Water Soluble Upper GI Paravertebral Nerve Block (Single) Breast Lesion Localization – Right Paravertebral Nerve Block (Multiple) Breast Surgical Specimen GENITOURINARY Epidural Injection Antegrade Pyelogram Facet Injection – Single Lumbar Cystogram Facet Injection – Each Additional Puncture Cystogram w/Voiding