THE HEALTHKIRKLIN CLINIC / Patient Name:_____________________________________________ AFFILIATEDSYSTEM CLINICS Date of Birth:______________________________________________ Medical Record Number:____________________________________ Department of Radiology RadiologyOrders for Research Diagnostic Order Imaging Form Date of Service:___________________________________________ Physician: _______________________________________________ NOTE: THIS FORM IS TO BE COMPLETED ONLY IF ITEMS ARE TO BE BILLED TO A RESEARCH STUDY IRB: __________________________________________________________ Subject ID: ______________________________________________________ Name of Study: ________________________________________________ Name of Principal Investigator:_____________________________________ Name of Study Coordinator:______________________________________ Telephone #:_______________________ Pager #_____________________ Name of Sponsor: ______________________________________________ Special Instructions:______________________________________________ SPECIAL SERVICE REQUEST: Data Transfer to Sponsor Paperwork to be Completed by Radiology Pre-Site Questionnaire Questionnaire Relating to Patient Scan Pantom Scan Other: Without Contrast With Contrast Without followed with Contrast Signed Order in Clinic Chart Please note: Any exam requiring contrast administration, CT or MRI, must have a current (< 90 days) creatinine. If renal function was abnormal, a more recent value would be required. Completed By:__________________________________________________________________ RECIST Criteria Physician Signature:_____________________________________________________________ *Indicates Prep Required √ GI/GU Imaging √ Ultrasound Imaging√ MRI Abdomen/KUB/Abdominal Series * Abdomen Head-MRI * Barium Swallow * Abdomen with Dopplers Brain * Enema Barium * Aorta Facial Bones/Sinuses * Enema Water Soluble Carotid Orbits * Esophogram - Modified Diagnostic Paracentesis MRA (intracranial) * Esophogram - Water Soluble Diagnostic Thoracentesis MRV * IVP Fine Needle Aspiration: Cisternogram Retrograde Urethrogram Groin CSF Flow Study * Small Bowel Series Lower Extremity Veins Perfusion T-Tube Choleangiogram Mark for Liver Biopsy Spectroscopy * Upper GI Parathyroid TMJ * Upper GI Water Soluable Pelvis Other VCUG Penile Neck-MRI Other Post-Op Arm Cervical Spine Bone and General Imaging Renal Soft Tissue Neck AC Joints Renal Transplant Brachial Plexus RL Ankle RL Renal with Dopplers MRA (Extracranial-Arch to Circle of Willis) Cervical Spine Scrotal MRA Subclavian Only RL Chest Soft Tissue Other Clavicle RL Therapeutic Paracentesis Torso-MRI Elbow RL Therapeutic Thoracentesis Breast Femur RL Thyroid Chest Wall (Musculoskeletal) Foot/Toe RL Upper Extremity Veins Ribs Forearm RL Vein Mapping Thoracic Spine Hand/Finger RL Other Abdomen Hip RL Cat Scan MRA (specify) Humerus RL Neuro-CT MRV (specify) Knee RL Cervical Spine Body Pelvis (i.e. fibroids) Lower leg RL * CTA (angio) Head Bony Pelvis Lumbar Spine RL * CTA Neck Lumbar Spine Mandible RL * Head Lumbar Plexus Pelvis RL Lumbar Spine Sacrum Ribs * Neck Gluteus Scapula RL * Orbits Spectroscopy Scoliosis Series R L * Maxillo/Facial (non-sinusitis) Other Shoulder Sinus/ (sinusitis) Extremity-MRI SI Joints RL * Temporal Bones/IAC Ankle RL Sinuses Thoracic Spine Ankle with Arthrogram RL Skull Chest-CT Elbow RL Sternum * Chest Elbow with Arthrogram RL Thoracic Spine * Chest for PE Femur/ Thigh RL Water's View Sinus * CTA Chest Foot RL Wrist RL High Resolution Chest Forearm RL Other Body-CT Hand RL Mammography * 3 Phase Liver Hip RL Breast Ultrasound * 3 Phase Liver with Pelvis Hip with Arthrogram RL Core Biopsy * 3 Phase Pancreas Humerus RL Diagnostic Mammogram * 3 Phase Pancreas with Pelvis Knee RL Pre-Operative Localization * Abdomen and Pelvis Knee with Arthrogram RL Screening Mammogram * Abdomen Only MRA (specify) Ultrasound Guided Aspiration * Adrenal MRV (specify) Ultrasound Guided FNA * CTA Abdomen and Pelvis Shoulder RL Other * CTA Runoff Shoulder with Arthrogram R L * Enterography Tibia/ Fibula/Calf RL Clinic:_________________________________ * Pelvis Only Wrist RL Renal for Kidney Stones Wrist with Arthrogram RL Contact Person: ________________________ * Renal Donor Other Contact Phone:_________________________ * Renal for all other 3D Reconstructed Images of MRI Musculosketal-CT Appt Date/Time:_________________________ Bony Pelvis If this patient should require anxiety management for MRI, please have the physician circle the medication of choice and sign the request. Patient will need to Lower Extremity (specify) RL arrive one hour prior to appointment and bring responsible driver. Request must be faxed to 205 731-5688 Sacrum Ativan 1 mg-2mg PO x 1 dose SI Joints Valium 5 mg-10 mg PO x 1 dose If the patient is scheduled for an MRI, please ask the Upper Extremity (specify) R L Xanax 0.25 mg- 0.5 mg PO x 1 dose patient to call 205 502-9933 for the pre-screening Other MRI safety Interview. 3D Reconstructed Images of CT ________________________________________________________________ Pet Scan Physician Signature Date Whole Body PET.