______Appt. Date
______Appt. Time Please Select Facility q ARLINGTON ARBROOK BLVD. q BURLESON q DALLAS FOREST LANE q DT FT WORTH q FOSSIL CREEK q GRAND PRAIRIE 817-472-0801 817-447-3443 214-369-3795 817-922-7780 817-428-5002 972-579-4480 Fax: 817-472-0840 Fax: 817-447-9094 Fax: 866-225-8389 Fax: 817-768-3255 Fax: 817-428-8101 Fax: 972-579-3909 q HURST q KELLER q LEWISVILLE q MESQUITE q NORTH GARLAND q RED OAK 817-498-6575 817-482-2000 972-434-6737 972-289-5558 972-495-7756 972-617-7731 Fax: 817-498-8854 Fax: 817-482-2050 Fax: 972-434-6739 Fax: 972-289-5786 Fax: 972-495-1837 Fax: 214-736-9234 Patient Name:______Sex: m Male m Female DOB:______Cell Phone:______Home/Work Phone: ______Insurance:______Insurance ID#:______Authorization:______
Referring Physicians Signature: q STAT ______q CALL ______May modify exam at radiologists Scan as Ordered Cell phone # discretion if clinically indicated Print Referring Dr.:______Referring Office Contact:______Date Ordered:______Office Phone:______Office Fax:______
❍❍ Screening Mammogram w/ call back visit: If a screening mammogram is abnormal, inconclusive, or ❍❍ MRI: questionable, then perform these additional diagnostic exams: diagnostic mammogram/sonogram Exam Requested______❍❍ Screening Mammogram (Routine/No Problems) ______
Symptomatic Exam m With/Without Contrast m Without Contrast ❍❍ Diagnostic Mammogram with Breast Ultrasound, ❍❍ CT: if needed – m Left m Right m Bilateral Exam Requested______Please check a diagnosis: ______m Abnormal mammogram m Pain RIGHT LEFT m Follow-up to biopsy m Follow-up to previous reported abnormal findings m Without m With m With/Without m History of breast cancer m Other ______❍❍ US: m Lump ______Exam Requested______❍❍ Bilateral Breast MRI (Downtown Fort Worth, Keller, Lewisville & Red Oak Locations Only) ______(with second look breast ultrasound if needed) m with and without contrast (lesion detection) ❍❍ X-Ray: m without contrast (for implant integrity only) Exam Requested______Please check a diagnosis: ______m Abnormal mammogram m Pain m Follow-up to biopsy m Follow-up to previous reported abnormal findings ❍❍ Fluoroscopy: m History of breast cancer m Other ______Exam Requested______m Lump ______❍❍ Bone Density/Osteoporosis Screening ______Diagnosis
To expedite interpretation, have the patient bring previous mammogram exam reports and images. Touchstone Locations Offering Mammography: Other Touchstone Locations:
Arlington Arbrook Blvd. Grand Prairie North Dallas McKinney 817.472.0801 | 817.472.0840 fax 972.579.4480 | 972.579.3909 fax 972.560.9000 | 214.989.6684 fax 214.250.5090 | 214.250.5095 fax 601 W. Arbrook Blvd. 2740 N. State Hwy. 360, Suite 200 9101 North Central Expressway, Suite 100 5321 W. University Arlington, TX 76014 Grand Prairie, TX 75050 Dallas, TX 75231 McKinney, TX 75071 MRI [Wide-Bore] • CT • US • X-Ray/Fluoro MRI [HF] • CT • US • X-Ray/Fluoro MRI [HF] • CT • US • X-Ray/Fluoro MRI [Wide-Bore] • CT • US • X-Ray/Fluoro Mammo [3D] • Bone Density • Arthrogram Mammo [3D] • Bone Density • Arthrogram Arthrogram • Calcium Scoring Arthrogram Segmental Pressures Denton Plano Burleson Hurst 940.320.6901 | 940.320.6969 fax 972.378.6858 | 972.378.9088 fax 817.447.3443 | 817.447.9094 fax 817.498.6575 | 817.498.8854 fax 1435 S. Loop 288, Suite 101 3304 Communications Pkwy., Suite 201 665 N.E. Alsbury Blvd. 1717 Precinct Line Rd., Suite 103 Denton, TX 76205 Plano, TX 75093 Burleson, TX 76028 Hurst, TX 76054 MRI [Wide-Bore] • CT • US • X-Ray MRI [3T & 1.5T Wide-Bore] • CT • US MRI [Wide-Bore] • CT • US • X-Ray MRI [Wide-Bore] • CT • US • X-Ray/Fluoro X-Ray/Fluoro • Arthrogram • Myelogram Mammo [3D] • Bone Density Mammo [3D] • Bone Density Arthrogram • Calcium Scoring Flower Mound Richardson Dallas Forest Lane Keller 972.724.0100 | 972.724.4455 fax 972.744.0882 | 972.744.0884 fax 214.369.3795 | 866.225.8389 fax 817.482.2000 | 817.482.2050 fax 3000 Corporate Court, Suite 400 1910 N. Collins Blvd. 11617 North Central Expressway, Suite 132 601 South Main Street, Suite 100 Flower Mound, TX 75028 Richardson, TX 75080 Dallas, TX 75243 Keller, TX 76248 MRI [Wide-Bore] • CT • US • X-Ray/Fluoro MRI [HF] • CT • US • X-Ray MRI [HF] • CT • US • X-Ray/Fluoro MRI [Wide-Bore] • CT • US • X-Ray/Fluoro Arthrogram Mammo [3D] • Bone Density • Arthrogram Mammo [3D] • Bone Density • Arthrogram Myelogram • Calcium Scoring Downtown Fort Worth PET/CT Southlake 817.335.5370 | 817.335.5318 fax 817.424.4800 | 817.305.5050 fax Downtown Fort Worth Lewisville 1263 West Rosedale, Suite 105 925 E Southlake Blvd., Suite 220 817.922.7780 | 817.768.3255 fax 972.434.6737 | 972.434.6739 fax Fort Worth, TX 76104 Southlake, TX 76092 1701 West Rosedale 190 Civic Circle, Suite 110 PET/CT • Calcium Scoring MRI [Wide-Bore] • CT • US • X-Ray/Fluoro Fort Worth, TX 76104 Lewisville, TX 75067 Arthrogram • Myelogram • Calcium Scoring MRI [3T Wide-Bore, HF] • CT • US MRI [HF] • CT • US • X-Ray X-Ray/Fluoro • Mammo [3D] • Bone Density Mammo [3D] • Bone Density Southwest Fort Worth Waco Arthrogram • Myelogram 817.294.1131 | 817.294.3882 fax 254.755.4410 | 254.755.4413 fax Fossil Creek Mesquite 6900 Harris Pkwy., Suite 100 312 Richland West Circle 817.428.5002 | 817.428.8101 fax 972.289.5558 | 972.289.5786 fax Fort Worth, TX 76132 Waco, TX 76712 5455 Basswood Blvd., Suite 550 1425 Gross Rd., Suite 130 MRI [HF] • CT • US • X-Ray/Fluoro MRI [HF Open MRI] • CT • US • X-Ray/Fluoro Arthrogram Fort Worth, TX 76137 Mesquite, TX 75149 Advanced Imaging Center MRI [Wide-Bore] • CT • US • X-Ray MRI [Wide-Bore, HF] • CT • US South Irving 972.560.9000 | 214.989.6684 fax Mammo [3D] • Bone Density • Arthrogram X-Ray/Fluoro • Mammo [3D] 469.299.8549 | 469.299.8547 fax 411 N. Washington Ave., Suite 1000 Bone Density • Arthrogram 2005 West Park Drive, Suite 110 Dallas, TX 75246 North Garland Red Oak Irving, TX 75061 MRI [3T Wide-Bore, HF] • CT • X-Ray/Fluoro 972.495.7756 | 972.495.1837 fax 972.617.7731 | 214.736.9234 fax MRI [HF] • CT • US • X-Ray Myelogram 7217 Telecom Pkwy., Suite 150 305 East Ovilla Road Arthrogram Garland, TX 75044 Red Oak, TX 75154 Baylor Diagnostic Imaging Center MRI [Wide-Bore] • CT • US MRI [HF] • CT • US • X-Ray/Fluoro Las Colinas at Junius X-Ray/Fluoro • Mammo [3D] Mammo [3D] • Bone Density • Arthrogram 214.647.6161 | 214.647.6162 fax 972.560.9000 | 214.989.6684 fax Bone Density • Arthrogram 440 W I 635, Suite 110 3900 Junius Street, Suite 100 Irving, TX 75063 Dallas, TX 75246 MRI [Wide-Bore] • CT • US • X-Ray MRI [3T Wide-Bore, HF] • CT • PET/CT US • X-Ray/Fluoro • Arthrogram Mansfield Calcium Scoring • Segmental Pressures 682.518.1234 | 682.518.8726 fax Baylor Charles A. Sammons 1750 Broad Park Circle South, Suite 300 Cancer Center Mansfield, TX 76063 972.560.9000 | 214.989.6684 fax MRI [HF] • CT • US • X-Ray 3410 Worth Street, Suite 770 Dallas, TX 75246 www.touchstoneimaging.com MRI [Wide-Bore]