n Athens (M & B Imaging – MRI, CT) n Gainesville (M & B Imaging – MRI, CT) n Augusta (MRI, CT, US) n Hiram (MRI) n Buckhead (ProRadiology – MRI, CT) n Johns Creek (ProRadiology – MRI, CT) n Canton (MRI, CT, US, Arthrogram, Myelogram) n Lawrenceville (MRI, CT, US, Arthrogram) n Conyers (Synergy Radiology – MRI) n Marietta (MRI, CT) n Cumming (MRI, CT, US, Arthrogram) n Newnan (MRI, CT, US, Arthrogram) n Decatur (MRI, CT, US, Arthrogram, Myelogram, X-RAY, Fibroscan) n Sandy Springs (MRI, CT, US, Arthrogram, Myelogram) n Fayetteville (MRI, CT, US) n Stand-Up MRI (MRI) See reverse for location addresses & phone numbers n West Cobb (MRI, CT, US, Arthrogram) Patient Name: DOB: Patient Phone #: n Call patient to schedule appointment Insurance Name: Auth#: Diagnosis: Contact Name: Contact Phone #:

n CD n Report Only Creatinine: _____ GFR: _____ Date Drawn: n STAT n CALL REPORT TO: ______Appt. Date: ______Appt. Time: ______AM / PM MRI ANGIOGRAPHY n WITHOUT n WITH n WITH & WITHOUT n MR Angiography n CT Angiography n Brain n Chest n Pelvic (Boney) n WITHOUT n WITH n WITH & WITHOUT n Pituitary n Abdomen n Female n Portal Vein - Inf. Vena Cava n Abdominal/Pelvic Arteries n IAC’s n Enterography n TMJ n Upper Extremity n LT n RT n n Orbits n Liver n Soft Tissue (Neck) Abdominal Aorta & Runoff n C-Spine n Fat Quantification n Brachial Plexus n Lower Extremity n LT n RT n Circle of Willis (Head) n T-Spine/Dorsal n MRCP n Breast (Decatur, n Aorta - Thoracic n Carotids (Neck) Lawrenceville, Sandy n n (Soft Tissue) L-Spine Pelvis Springs) n Aorta - Abdominal n n Sacrum Prostate (Sandy n Breast Rupture Springs only) Protocol ULTRASOUND n LEFT n RIGHT n BILATERAL n Soft Tissue Neck n Thyroid n Extremity Non-Vascular n Shoulder n Elbow n Wrist n Hand

n Hip n Knee n Ankle n Foot n Retroperitoneal Renal n Scrotum n Carotid Bilateral

n Other ______n Lower Extremity Venous, Bilateral n n n ARTHROGRAMS/MYELOGRAMS Lower Extremity Venous, Unilateral LT RT n Upper Extremity Venous, Bilateral n LEFT n RIGHT n BILATERAL n Upper Extremity Venous, Unilateral n LT n RT n Intra-articular Contrast (Joint/Arthrogram) n MRI n CT n Aorta n Shoulder n Elbow n Wrist n Myelogram n Transvaginal n Renal with Doppler n Hand n Hip n Knee n Cervical n Pelvic, Non-OB limited n Limited Liver with Doppler n Thoracic n Ankle n Foot n Pelvic, Non-OB complete n Abdomen, Limited, Quadrant n Lumbar n Renal/Bladder n Abdomen, Complete CT n WITHOUT n IV ONLY (no oral) n ORAL & IV X-RAY (Decatur Only) n Brain n Pelvis n Chest n Orthopedic: n n n n Sinus n Abdomen/Pelvis n PE Protocol (CTA) Right Left Bilateral

n Sinus Stealth n Stone (NO ORAL) n Calcium Scoring n Chest n Abdomen n Spine n Flex/Ext n IAC’s/Temporal n Urogram n C-Spine n Other: n Orbits n Enterography w/IV n T-Spine ATTORNEY n Soft Tissue Neck n Renal (wo/w IV) n L-Spine n Abdomen n Liver (wo/w IV) ICD-10 Code / Diagnosis:

n LEFT n RIGHT n BILATERAL Attorney Name:

n Shoulder n Elbow n Wrist n Hand Attorney Number: Date of Injury: n Hip n Knee n Ankle n Foot n Work Comp n MVA n Slip & Fall

Physician Signature: Date:

Physician Name: Physician Phone: