Date: ______REFERRING PROVIDER INFORMATION: Scheduling: 206.292.7734 Provider Name: ______Fax: 206.292.6371 EHR: 206.292.7744 www.searad.com Provider Signature: ______PATIENT INFORMATION: Office Contact Name: ______Patient Name: ______DOB: ____/____ /_____ Phone: ______Phone: Cell/Other: ______Home: ______After Hours Phone: ______Insurance Company: ______Insurance ID: ______Routine Report: Faxed within 24 hours Auth #: ______Valid from: ______to: ______ASAP Report: Faxed within 2 hours MEDICARE CDS INFO CDSM/G-Code: ______STAT Report: Immediate Report Faxed Outcome/Modifier: ______for Critical Results Fax number: ______HISTORY / SYMPTOMS / DIAGNOSIS (RULE-OUT TO INCLUDE HISTORY): Call Report: ______phone number ______PET-CT SPINE INJECTIONS ICD-10 Code: ______FDG Brain Treatments: 1x Up to 3x FDG Whole body Epidural C-Spine

CT SCAN MRI SCAN ULTRASOUND Skull Base to Mid-Thigh Epidural L-Spine

Contrast options: Contrast options: Transvaginal as clinically FDG Nerve Root Block/

prn w/ w/o wwo prn w/ w/o wwo indicated, OR Axumin Transforaminal

Head Brain No Transvaginal Netspot Lumbar Side & Level:

Temporal Bone Pituitary Thyroid Additional contrast ______

Orbits Orbits Fine Needle Aspiration enhanced CT ______Facet Joint Injection

Sinuses Neck Soft Tissue Site: ______Neck Lumbar Side & Level:

Neck Soft Tissue Cervical Spine Carotid Duplex Chest ______

Chest Low Dose Chest Thoracic Spine Aorta Abdomen SI Joint

Abdomen Lumbar Spine Soft Tissue Pelvis KUB Low Dose KUB Chest Body Part: ______JOINT INJECTIONS

IVP Abdomen/Liver Studies Low Ext Venous Duplex ARTHROGRAM Shoulder L / R

Pelvis SI Joints Abdomen - complete Arthrogram/CT Elbow L / R

Enterography Pelvis Abdomen - limited organ: Arthrogram/MRI Wrist L / R

Enterography ______Shoulder L / R Hip L / R

Specify Level Prostate Abdomen with liver doppler Elbow L / R Knee L / R

C-Spine: ______Rectal Renal Wrist L / R Ankle L / R

T-Spine: ______Shoulder L / R Pelvic Hip L / R Foot L / R

L-Spine: ______Hip L / R Pelvic w/ Transvaginal Knee L / R Other: ______L / R Ankle L / R Extremity Upper Knee L / R Scrotal Marcaine Only Other: ______L / R ______L / R Wrist L / R Scrotal w/ Doppler Steroid Only Extremity Lower Ankles/Foot L / R Inguinal Hernia Marcaine & Steroid ______L / R Hand/Finger L / R Obstetric ASPIRATIONS Wrist/Hand L / R Extremity Upper: EDC or LMP: ______Shoulder L / R X-RAY Hip L / R Ankles/Foot L / R ______L / R Week: ______(Walk-in or by appointment, Knee L / R Cardiac/Calcium Score Extremity Lower: Other: ______8:00am - 4:30pm, M-F) ______L / R Chest Other: BREAST IMAGING PUNCTURES Kub Abdomen ______Lumbar Puncture MRI ANGIO Ultrasound Breast L / R Hip L / R Opening Pressure: Brain Ultrasound Knee L / R CT ANGIO Yes No Neck Breast Biopsy L / R Hand L / R Head ICD-10 Code: ______Aortic Arch/Thoracic Wrist L / R Neck Labs: Please fax. Abdomen Ankle L / R Bilat Ext Runoffs Bilat Ext Runoffs Foot L / R Chest MYELOGRAM Shoulder L / R Abdomen BREAST IMAGING Myelogram w/CT Pelvis Cervical MRI Breast Other: ______Coronary Thoracic MRI Breast Biopsy L / R ______Renal Lumbar Implant Protocol ______

Rev 12/19 Date: ______REFERRING PROVIDER INFORMATION: PatientPatient PreparationPreparation DrivingDriving Directions Directions Provider Name: If you have any questions about patient

If you have any questions about patient SUMMIT FIRST HILL PLAZA Scheduling: 206.292.7734 Provider Signature: preparation, please call us at 206.292.7734. MADISON preparation, please call us at 206.292.7734. BOYLSTON NORDSTROM PAV Fax: 206.292.6371 EHR: 206.292.7744 Contra indications include cardiac pacemakers, aneurysm clips, cochlear im- ARNOLD MEDICAL TOWER www.searad.com Office Contact Name: Contra indications include cardiac pacemakers, aneurysm clips, ILION plants, pregnancy and/or metal in the eyes. 1101 MADISON SATURDAY APPOINTMENTS AVAILABLE Phone: cochlear implants, pregnancy and/or metal in the eyes. BUILDING PARKING MARION After Hours Phone: MRI MRI HUTCHINSON CANCER PATIENT INFORMATION: ExamsExams with with oral oral sedation sedation will requirerequire a drivera driver to accompanyto accompany patients. patients. RESEARCH

SWEDISH HOSPITAL HEATH BUILDING Patient Name: DOB: / / Routine Report: Faxed within 24 hours Abdomen/Liver/MRCP:Abdomen/Liver/MRCP: Nothing Nothing to eateat or or drink drink for for at leastat least 4 hours 4 hours prior priorto your SWEDISH MAIN

to yourexam. exam. COLUMBIA ENTRANCE Phone: Cell/Other Home ASAP Report: Faxed within 2 hours MINOR Enterography:Enterography: Nothing Nothing toto eat or or drink drink for for 4 hours 4 hours prior prior to your to yourexam. exam. Arrive 1 BORE N Insurance Company: STAT Report: Immediate Report Faxed Arrive 1 hour prior to exam. hour prior to exam. SOUTH PAVILION for Critical Results SEATTLE UNIVERSITY BROADWAY

Insurance ID: Prostate:Prostate: Nothing Nothing to to eat eat or drinkdrink after after midnight. midnight. Arrive 1 hour prior to NW CHERRY KIDNEY Fax number: exam. CENTER Rectal: Fleet enema prep, nothing to eat or drink after midnight. SWEDISH Auth # Valid from: to: ORTHOPEDIC Call Report: Rectal: Nothing to eat or drink after midnight. Arrive 1 hour prior to INSTITUTE 600 phone number exam. PARKING HISTORY / SYMPTOMS / DIAGNOSIS (RULE-OUT TO INCLUDE HISTORY): CT BROADWAY = Seattle Radiologists Building JAMES PET-CT SPINE INJECTIONS Abdomen CT and/or Pelvis: Nothing to eat for at least 2 hours prior to your exam. AbdomenDrink plenty and/or of water. Pelvis: Nothing to eat for at least 2 hours prior to your F18 NaF Oncologic Bone Scan Treatments: 1x Up to 3x exam.Head, Drink Neck plenty and Chest: of water Nothing. to eat for at least 2 hours prior to your exam. NordstromNordstrom Medical Medical Tower Tower ICD-10 Code: ______FDG Brain Epidural C-Spine Head,Drink Neck plenty and of Chest: water. Nothing to eat for at least 2 hours prior to your 12291229 Madison, Madison, Suite Suite 900 900, Seattle, Seattle, WAWA 9810498104 FDG Whole body Epidural L-Spine exam.Spine Drink and plenty extremities: of water No preparation. necessary. Skull Base to Mid-Thigh FROM THE NORTH FROM THE SOUTH CT SCAN MRI SCAN ULTRASOUND FROM THE NORTH FROM THE SOUTH FDG Nerve Root Block/ Spine and extremities: No preparation necessary. l Travel on I-5 South l Travel on I-5 North Doppler as clinically indicated, Contrast options: Contrast options: Transforaminal • Travel on I-5 South • Travel on I-5 North Axumin l Take exit 165A toward James Street l Take exit 164A for Dearborn Street w/ w/o wwo prn w/ w/o wwo prn OR No Doppler EPIDURAL, NERVE ROOT BLOCK OR FACET • Take exit 165A toward James Street • Take exit 164A for Dearborn Netspot Lumbar Side & Level: toward James Street / Madison Street Transvaginal as clinically EPIDURAL, NERVE ROOT BLOCK l Turn• Turn left ontoleft onto Cherry Cherry Street Street Street toward James Street / Oral Sedation Needed? JOINT INJECTION l Follow signs for I-5 N / Vancouver BC / Head indicated, OR No Transvaginal Additional contrast l Take the first left onto 7th Avenue OR FACET JOINT INJECTION • Take the first left onto 7th Avenue Madison Madison Street Street / Convention Center Temporal Bone Brain l Thyroid enhanced CT Facet Joint Injection Please contact our office if you are allergic to iodine (x-ray/ CT dye). Bring any Take• Take the thirdthe third right right onto onto • Follow signs for I-5 N / Pituitary Pleasepertinent contact x-rays our or office scans ifwith you you are for allergic comparison to iodine and to (x-ray/ avoid x-raysCT dye). being Madison Street l Keep right at the fork, follow signs Orbits Fine Needle Aspiration Neck Lumbar Side & Level: Madison Street for Vancouver Madison Street BC /Madison Orbits Bringre-taken. any pertinent x-rays or scans with you for comparison and to l Take a right onto Summit Street to Sinuses Chest l Site: avoid x-rays being re-taken. enter• Take parking a right garage onto Summit Street to Turn Street right / ontoConvention Madison Center Street Neck Soft Tissu Abdomen Neck Soft Tissue Carotid Duplex SI Joint All prescribed medications (except for blood thinners) should be taken as enter parking garage l Take• Keep a right right onto at the Summit fork, Street follow to Pelvis All prescribed medications (except for blood thinners) should be Chest Cervical Spine usual. A nurse will be contacting you to discuss pre-procedure instructions and enter signs parking for Madison garage Street Aorta taken as usual. A nurse will be contacting you to discuss pre-procedure • Turn right onto Madison Abdomen Thoracic Spine restrictions. You must have a driver with you as there is a chance that you could Soft Tissue instructions and restrictions. You must have a driver with you as there Street Lumbar Spine ARTHROGRAM JOINT INJECTIONS experience temporary numbness and/or weakness in one or both legs. You must Pelvis Body Part: is aspeak chance to ourthat nurse you beforecould havingexperience the exam temporary to review numbness other contraindicated and/or PET-CT - Patient Instructions• Take a right onto Summit Chest Arthrogram/CT Shoulder L / R Enterography Low Ext Venous Duplex weaknessmedications. in one Please or both call 206.292.6233.legs. You must speak to our nurse before Street to enter parking Abdomen/Liver Studies Arthrogram/MRI Elbow L / R having the exam to review other contraindicated medications. If she/ Lower Ext Arterial PRE-APPOINTMENT INSTRUCTIONS garage Specify Level SI Joints Wrist L / R he has not spoken to you, please take a moment to contact our nurse Duplex Abdomen Shoulder L / R C-Spine: Pelvis Hip L / R now byARTHROGRAM calling (206) 292-8525. In order to help us make your appointment more comfortable, Organ: Elbow L / R pleasePET-CT read the Patientfollowing instructions Instructions carefully. T-Spine: Enterography Knee L / R Please bring any pertinent x-rays or scans with you for comparison and to avoid Wrist L / R We ask that you dress warmly and try to avoid wearing anything L-Spine: Transplant: x-rays ARTHROGRAM being re-taken. Please contact our office if you are allergic to iodine (x-ray/ Prostate Ankle L / R with metal (including snaps, buttons and zippers). Renal Hip L / R PleaseCT dye). bring It isany not pertinent necessary x-raysto hold or any scans medicine, with includingyou for comparison blood-thinners. PRE-APPOINTMENT INSTRUCTIONS Extremity Upper Rectal Foot L / R Keep in mind your visit can take up to 2.5 hours. Pelvic Knee L / R L / R Other: L / R and to avoid x-rays being re-taken. Please contact our office if you Shoulder L / R In order to help us make your appointment more comfortable, Pelvic w/ Transvaginal Ankle L / R are allergic to iodine (x-ray/ CT dye). It is not necessary to hold any Pre-scan Instructions please read the following instructions carefully. Extremity Lower Hip L / R Scrotal Other: L / R Marcaine Only medicine, MYELOGRAM/LUMBAR including blood-thinners. PUNCTURE l NothingWe ask that but you water dress 8 warmlyhours before and try yourto avoid test. wearing anything L / R Knee L / R Steroid Only Please contact our office if you are allergic to iodine (x-ray/ CT dye). Scrotal w/ Doppler with metal (including snaps, buttons and zippers). l If you are a diabetic, please bring your insulin with you to your Wrist L / R Inguinal Hernia ASPIRATIONS Marcaine & Steroid MYELOGRAM/LUMBAR PUNCTURE Wrist/Hand L / R Please bring any pertinent x-rays or scans with you for comparison and to avoid appointment.Keep in mind your visit can take up to 2.5 hours. Ankles/Foot L / R Please contact our office if you are allergic to iodine (x-ray/ CT dye). Ankles/Foot L / R Ankle/Brachial Indices Shoulder L / R x-rays being re-taken. l Avoid exercise 24 hours prior to exam including long walks and Cardiac/Calcium Score Hand/Finger L / R Obstetric Please bring any pertinent x-rays or scans with you for comparison and Pre-scan Instructions Hip L / R X-RAY Please be sure to have a driver with you. yoga. Extremity Upper: to avoid x-rays being re-taken. • Nothing but water 8 hours before your test. EDC or LMP: Knee L / R (Walk-in or by appointment, After the procedure, please plan to remain in a flat or reclined position at home l Please remember to drink plenty of water prior to your exam. ______L / R Week: • If you are diabetic please without insulin for 6 hours prior Other: 8:00am - 4:30pm, M-F) Pleaseuntil be the sure next to morning. have a driver with you. Extremity Lower: l Take to yourmedications. appointment and bring your insulin with you to Other: PUNCTURES Chest After the procedure, please plan to remain in a flat or reclined ______L / R No solid food after midnight the night before your exam. (For Myelograms - Do you appointment. Kub/Abdomen positionnot consume at home anything until the containing next morning. caffeine 24 hours prior to the exam.) You must l Please call for additional instructions if you are breast feeding or Lumbar Puncture • Avoid exercise 24 hours prior to exam including long walks CT ANGIO Hip speak to our nurse before having the exam to review other contraindicated have infants and/or toddlers. MRI ANGIO BREAST IMAGING Opening Pressure: No solid food after midnight the night before your exam. (For and yoga. Head Contrast options: Knee L / R Myelogramsmedications. - Do Please not call consume 206.292.6233. anything containing caffeine 24 hours w/ w/o wwo prn Ultrasound Breast L / R Yes No • Please remember to drink plenty of water prior to your exam. Neck Hand L / R prior to the exam.) You must speak to our nurse before having the Brain Ultrasound exam to review other contraindicated medications. If she/he has not Bilat Ext Runoffs ICD-10 Code: Wrist L / R ULTRASOUND • Take medications. Neck Breast Biopsy L / R Labs: Please fax. Other spoken to you, please take a moment to contact our nurse now by Chest Pelvic or OB<14 weeks: drink 32 oz of water 1 hour before test. • Please call for additional instructions if you are breast feeding or Aortic Arch/Thoracic calling (206) 292-8525. Abdomen have infants and/or toddlers. Abdomen Renal: Drink 32 oz of water 1 hour before test. Pelvis MYELOGRAM Bilat Ext Runoffs Abdomen, ULTRASOUND gallbladder, aorta and organs: Nothing to eat or drink for 8 hours Coronary Myelogram w/CT Pelvicbefore or OB<14test. weeks: drink 32 oz of water 1 hour before test. Renal BREAST IMAGING Cervical MRI Breast Thoracic Renal: Drink 32 oz of water 1 hour before test. MRI Breast Biopsy L / R Lumbar Abdomen, gallbladder, aorta and organs: Nothing to eat or drink for 8 Abbreviated Breast MRI hours before test.

January 2019