DIAGNOSTIC IMAGING, P.C. 6401 POPLAR AVENUE, SUITE 100, MEMPHIS, TENNESSEE 38119 www. diagnosticimagingpc .com Edward Atkinson, III, M.D. PHONE (901) 387-2340 Louis S. Parvey, M.D. Robert A. Duke, M.D. FAX (901) 680-1902 Graham L. Roberts, M.D. K Diagnostic Imaging, P.C. to schedule patient. Appointment Date:______________ Time:______________am/pm (To be completed after appointment is scheduled) Patient Name ____________________________________________________________________ K M K F Date of Birth________________ Weight_________ Referring Physician/Provider __________________________________________________________Phone______________________________________________ Clinical History ________________________________________________________________________________________________________________________ REFERRING PHYSICIAN/PROVIDER SIGNATURE (Required) __________________________________________________ Complete section below for fax scheduling only. Patient Home Phone ________________________________________________________ Patient Alternate Phone_______________________________________ Primary Insurance __________________________________________________________ Secondary Insurance_________________________________________ Precert/Referral # (if available) ____________________________________________________________________________________________________________ Please indicate the requested examinations or procedure below. If not listed, please specify the desired examination. BREAST IMAGING XRAY / FLUOROSCOPY MRI / MRA K Diagnostic Mammogram Creatinine levels are required for all patients 60 and over or XRAY who have diabetes or renal failure, if IV contrast is ordered. K Screening Mammogram K Abdomen/KUB K Creatinine/BUN (if indicated) K Breast Ultrasound R/L/Bil K Bone Age Study K Ankle MRI K R K L K Additional Views (Mammo) K Cervical Spine Series K Brain MRI K Chest X-ray K Cervical Spine MRI CT SCANS K Lumbar Spine Series K Elbow MRI K R K L Creatinine levels are required for all patients 60 and over or K Sinus Series who have diabetes or renal failure, if IV contrast is ordered. K Foot MRI K R K L K Thoracic Spine Series K Creatinine/BUN (if indicated) K Hip MRI K R K L K Other – Please specify K Abdomen and Pelvis CT K Internal Auditory Canals MRI K Bone Density Screening/QCT ______________________________________ K Knee MRI K R K L K Brain CT K Lumbar Spine MRI K Cardiac Score FLUOROSCOPY K Shoulder MRI K R K L K Cervical Spine CT Creatinine levels are required for all patients 60 and over or K Thoracic Spine MRI K Chest CT who have diabetes or renal failure, if IV contrast is ordered. K Wrist MRI K R K L K Kidney or Adrenal CT K Creatinine/BUN (if indicated) K Head MRA K Kidney Stone CT K Arthrography: Shoulder K R K L K Neck MRA K Liver/Spleen CT K Barium Enema K MR Arthrogram: K Lumbar Spine CT K Barium Enema with Air Contrast Shoulder/Knee/Wrist/El bow/Ankle K Lung Screening K Esophagram K K Other – Please specify Pelvis CT K Hip Injection K R K L K ______________________________________ Post Myelogram CT C/T/L Spine K IVP K Sinus CT K Myelography: Cervical or Lumbar K Soft Tissue Neck CT ULTRASOUND K Small Bowel Follow Through K Thoracic Spine CT K K Upper GI Abdomen US K 3D Rendering on Independent K K VCU Duplex Arterial US __________________ Workstation (if clinically indicated) K Duplex Carotid US K K Other – Please specify Other – Please specify K Duplex Venous US __________________ ______________________________________ ______________________________________ K Echocardiogram K NUCLEAR IMAGING Neck (Soft Tissue) US CT ANGIOGRAPHY K Pelvis US K K K Bone Scan 3 phase K Renal US Aorta CTA K K K Hepatobiliary Scan w/ cck K Brain CTA K Testicular/Scrotum US K Liver Scan K Carotid CTA K Transvaginal Pelvis US K Lower Extremity Runoff CTA MUGA K K Other, please specify K Pulmonary CTA Thyroid Uptake/Scan K ______________________________________ K Renal CTA Other – Please specify K Other – Please specify ______________________________________ ______________________________________ Form must be received prior to patient’s scheduled appointment or presented by the Rev. 11/14 patient at their scheduled appointment time. DIAGNOSTIC IMAGING, P.C. 6401 POPLAR AVENUE, SUITE 100, MEMPHIS, TENNESSEE 38119 www. diagnosticimagingpc .com PHONE (901) 387-2340 FAX (901) 680-1902 PATIENT INSTRUCTIONS PLEASE FOLLOW THE PERTINENT EXAM INSTRUCTIONS UNLESS OTHERWISE INDICATED BY YOUR PHYSICIAN CT & CTA MRI/MRA ABDOMEN / ABDOMEN & PELVIC CT • Wear comfortable clothing with no metal. Nothing to eat or drink for 3 hours before the scan other than the oral • Patients with pacemakers and aneurysm clips, depending on the location contrast that you will be given at our office under our supervision in the body, are prohibited from having a MRI scan. CHEST/THORAX CT NUCLEAR IMAGING Nothing to eat or drink 2 hours before the scan CTA BONE SCAN o preparation needed, but wear comfortable clothing with no metal. Nothing to each or drink 2 hours before the scan N KIDNEY STONE CT HEPATOBILIARY SCAN(DISIDA) Nothing to eat or drink 8 hours before the test but no more han 18 hours . No preparation needed • t • No opiate based pain medication for 48 hours prior. FLUOROSCOPIC STUDIES KIDNEY IMAGING BARIUM ENEMA (BE) Drink an increased amount of fluids for 24 hours before the test. Call office for prep or visit our website www.diagnosticimagingpc.com THYROID UPTAKE AND SCAN ARTHROGRAPHY • Nothing to eat or drink 4 hours before the 1st of 2 appointments Anticoagulants (blood thinners) other than aspirin should not be taken for • No IV contrast studies within 4 weeks (ex. Heart cath, IVP, CT scan) the period of time defined in the Diagnostic Imaging PC Anticoagulant • No antihistamines, vitamins containing iodine, seaweed or sushi within 2 weeks Prep List. The number of days and/or hours a patient should be off the • No steroids within 1 week medication will vary based on the particular anticoagulant. Consult I-131 THYROID THERAPY (Thyroid Ablation) with your referring provider or call our office for specific instructions Must have had a Thyroid Uptake/Scan within one month prior. before discontinuing any anticoagulant or prescribed medication. HIP INJECTION ULTRASOUND Same prep as Arthrography ABDOMEN IVP (Liver, Gallbladder, Pancreas, and Spleen) Call office for prep or visit our website www.diagnosticimagingpc.com Nothing to eat or drink for 8 hours before the test. (Children under 12 may have a normal diet unless the gallbladder is to be evaluated.) MYELOGRAPHY CERVICAL, THORACIC AND LUMBAR STUDIES PELVIS • No aspirin should be taken for 7 days before the procedure. It is necessary to have a full bladder for this test. Beginning about 2 hours before • Anticoagulants (blood thinners) other than aspirin should not be taken for the test you may need to drink 24-32 ounces of water in order to have a full the period of time defined in the Diagnostic Imaging PC Anticoagulant bladder. No carbonated drinks. Do not empty your bladder until after the test. Prep List. The number of days and/or hours a patient should be off the ABDOMEN AND PELVIS medication will vary based on the particular anticoagulant. Consult with If you are having both tests at the same visit, you may drink water only your referring provider or call our office for specific instructions before dis - but no food per Abdomen exam instructions above. continuing any anticoagulant or prescribed medication. • No tranquilizers should be taken for 48 hours before the procedure. RENAL (KIDNEY) • Drink an increased amount of fluids for 24 hours before the procedure. • Renal US – nothing to eat or drink except water for 4 hours before the test. • No solid foods should be consumed for 4 hours before the procedure. • Renal Doppler US – nothing to eat or drink except water for 8 hours before • Patient should have someone available to drive after the procedure is the test. completed. UPPER GI • Nothing to eat or drink for 8 hours before the test. • Children under 2 years old should have nothing to eat or drink for only 4 hours before the test. VCU No preparation needed MAMMOGRAPHY • Do not use deodorant, powders, ointment or perfume on your breasts or underarm area before the test. • Bring previous mammography films or arrange for them to be sent to us if prior studies were not performed at our facility. Rev. 11/14.