Imaging Services Order
PATIENT NAME: DOB: TODAY’S DATE: first name middle initial last name DAY PHONE: CELL: REFERRING PHYSICIAN: LAB USED: BUN/CREAT: DATE DRAWN: CLINIC BACK LINE PHONE: I-STAT: INSURANCE COMPANY: (if indicated) RESULTS DELIVERY: BY PHONE #: BY FAX #: (check preference) PATIENT TO CARRY CD IMAGES PATIENT TO CARRY FILMS DELIVER FILMS TO: INDICATION: SPECIAL REQUESTS/INSTRUCTIONS: PHYSICIAN SIGNATURE: PROVIDER ID: CT – Routine Examinations MR Examinations Ultrasound
CT CTA MRI MRA Abdomen Abdomen With Doppler Pelvis
With Contrast Without Contrast With Contrast Without Contrast With Transvaginal Brain Brain IAC Orbits Pituitary Trigeminal Obstetric (1st trimester)
Neck (soft tissue) Neck (soft tissue) With Transvaginal Chest Abdomen MRCP Obstetric (2nd/3rd trimester) (does not include pelvis unless pelvis also ordered) Abdomen Liver Pancreas Kidney Adrenal Testicular Prostate
Optional Organ-Focused: Pelvis Soft Tissue Pelvis Bony Renal/Retroperitoneal
Liver Pancreas Kidney Adrenal Brachial Plexus R L Bilateral Renal Renal With Renal Artery Doppler
Pelvis MRA: Aorta Carotid Arteries Renal Transplant
Facial Bones Renal Arteries Cerebral Thyroid
Orbits Mesenteric Arteries Breast R L Bilateral MRV (specify location) Temporal Bones : AAA
Sinus Landmark Instatrak Breast R L Bilateral Other: Spine: Cervical Thoracic Lumbar Spine: Cervical Thoracic Lumbar Extremity: MR Arthrogram: Nuclear Medicine Run-Off: Knee R L PET-CT Indication: Other: Shoulder R L Cardiac Viability Myocardial Perfusion Brain Hip R L Oncology (Please check Whole Body or Skull to Mid Thigh) CT – Specialized Examinations Wrist R L Whole Body Skull to Mid Thigh
Kidney Stone (for urinary tract calculi includes KUB) Ankle R L Bone 3 Phase Limited Whole Body
Enterography (replaces SBFT for most indications) Elbow R L SPECT Location:
Hematuria/CT IVP (w/u of painless hematuria includes 3D) Hand R L Plain Films per Radiologist as Necessary VQ Scan
High Resolution Chest (diffuse pulmonary disease) Foot R L Hepatobiliary: Scan EF (CCK)
Chest for Pulmonary Embolus Other: MUGA GI Empty
Low Dose CT Chest Lung Cancer Screening Myocardial Perfusion SPECT Renal Scan
CT Colonography X-Ray Parathyroid
CT Arthrogram Specify Joint: Chest 1 View 2 View Thyroid: Whole Body Diagnostic
Other: Abdomen KUB 3 View Other: Pelvis Breast Imaging Femur R L Cardiac Studies 3-D Mammography Screening (Bellevue) R L Bilateral Tib/Fib R L Cardiac CT Cardiac MR
3-D Mammography Diagnostic (Bellevue) R L Bilateral Ribs R L Bilateral Cardiac Nuclear Medicine Calcium Scoring 3-D Mammography Screening R L Bilateral Ribs (includes PA chest) Other:
3-D Mammography Diagnostic R L Bilateral Hip R L Bilateral
Stereotactic Biopsy R L Bilateral Knee R L Bilateral Fluoroscopy
MRI Guided Breast Biopsy Ankle R L Bilateral Barium Enema (BE) BE Without Air BE With Air
Breast Biopsy Needle Localization Foot R L Bilateral Esophagram UGI Ultrasound Guided Biopsy Shoulder R L Bilateral Lumbar Puncture
Breast Cyst Aspiration R L Bilateral Elbow R L Bilateral Modified Barium Swallow
Other: Wrist R L Bilateral Small Bowel Follow Through (SBFT) Consider CT enterography for most indications Hand R L Bilateral Hysterosalpingogram Cystogram Arthrogram DEXA DEXA Bone Densitometry Spine Cervical Thoracic Lumbar Myelogram IVP With Tomograms Standard 3 View With Obliques Flex/Ext Renal Stone CT or CT IVP suggested for most indications Interventional Radiology Sinuses VCUG Other: Consult Single Waters View Full Series Reason for Consult: Other: ORD-MR-0276 (Rev. 06/18)
Centralized Scheduling Interventional Radiology Preauthorization (for all locations) CONTACT p: 402.559.2500 fax: 402.559.3464 p: 402.559.8574 fax: 402.559.3050 p: 402.559.2110 fax: 402.559.9887 INFORMATION Bellevue p: 402.763.3400, option 1 fax: 402.763.3183 Bellevue p: 402.763.3400, option 1 fax: 402.763.3183 Imaging Services Order
MRI 1.5T MRI 3T PET-CT CT US X-RAY MAMMO DEXA NUC MED FLUORO IR SUITE 3D Hixson-Lied Center University Tower Doctors Tower South Olson Center for Women’s Health (Fourth Floor Durham Outpatient Center) Nebraska Medicine – Village Pointe Nebraska Medicine – Lauritzen Outpatient Center Fred & Pamela Buffett Cancer Center Nebraska Medicine – Bellevue VILLA E POINTE S OPPIN CENTER Locations
W CENTER ROAD
NEBRAS A MEDICINE – DOCTORS TOWER FARNAM STREET NORT MED CENTER CAMPUS FARNAM STREET W DOD E ROAD
DOCTORS TOWER PAR IN LOT SOUT N VILLA E POINTE VILLA E POINTE S OPPIN CENTER
IEWIT TOWER S WAL 44TH STREET S OPPIN CENTER T STREET
FRED & PAMELA PAR IN LOT BUFFETT CANCER CENTER DEWE AVENUE DEWE AVENUE CLAR SON TOWER
SADDLE CREE ROAD T STREET ENTRANCE IXSON-LIED CENTER BUR E STREET FREE VALET PARKING SADDLE CREEK ROAD UNIVERSIT DUR AM OUTPATIENT CENTER TOWER E M NEBRAS A MEDICINE – IL 45TH STREET E LOT 2 42ND STREET N T STREET T STREET ND STREET S T PATIENT VILLA E POINTE PAR IN ARA E R E PARKING ET SPECIALTY SERVICES EMILE STREET PAVILION EMILE STREET N Nebraska Medicine – Fred & Pamela Buffett Nebraska Medical Center Cancer Center Nebraska Medicine – 42nd St. and Dewey Ave. Omaha, NE 68198 505 S. 45th St. Omaha, NE 68105 Village Pointe 402.559.2500 402.559.1900 same day 111 N. 175th St. Omaha, NE 68118 402.596.3180 same day University Tower 4400 Emile St. (Circle Dr.) 402.559.2500 Hwy 370 Durham Outpatient Center Entrance Free Valet Parking* OSPITAL S. 25th Street
MEDICAL OFFICE Doctors Tower South 4239 Farnam St., Ste. 622 BUILDIN
402.559.2500 or 402.552.2777 ER Entrance Main Entrance 2500 Farnam Street Entrance Entrance 2510 Parking Lot Located East of Building P P Bellevue Medical Center Drive Durham Outpatient Center 4400 Emile St. (Circle Dr.) 402.559.2500 or 402.559.4500 Nebraska Medicine – Bellevue Durham Outpatient Center Entrance 2500 Bellevue Medical Center Drive Free Valet Parking* Bellevue, NE 68123 Nebraska Medicine – Hixson-Lied Center 402.559.2500 402.763.3400, option 1 Lauritzen Outpatient Center Durham Outpatient Center or Clarkson Tower Entrance 4014 Leavenworth St. Omaha, NE 68105 Free Valet Parking* 402.559.0769 same day * No tipping necessary for valet parking.
APPOINTMENT INFORMATION Date: Arrival Time: AM/PM Location: