Phone:  (727) 841-8212

Fax:      (727) 841-9589

Stat Exam

PLEASE NOTE: You can complete the patient referral process online by filling out this form and submit it to us with SEND button at the

bottom of the from, or, click here to print the Prescription Form and faxt it to us at 727.841.9585. Thank you very much for your referral!

Patient's Name:

Referring Dr.:    

Exam:  

Date:  

Time:  

Clinical History (Symptoms):  

Contrast Allergy?

Yes         No

Authorization #:

Previous Studies?

Yes         No

Where:

If STAT, phone report to:   

fax report to:  

Copy to Dr.:  

BUN:  

Creatinine:  

 

Physician's Signature:

(By checking this box I digitally sign this referral form)  

 

Physician's Address:

       

MRI

Without Contrast

With Contrast

With/Without Contrast

 

CT w/3D

Without Contrast

With Contrast

With/Without Contrast

 

4D Ultrasound

Non-Diagnostic 4D Ultrasound

(Performed at 29 to 32 weeks)

 

 

Echocardiogram

Echocardiogram with Pulse

Wave and Color Flow

 

 

Abdomen

Brain

Breast   R   L

Chest

Extremity   Upper   Lower

Site: R   L

Joint   Upper   Lower

Site: R   L

MR Arthrogram

Site:

Neck

Orbits/Face/Neck/(IAC/Pit)

Pelvis

Spine - Cervical

Spine - Lumbar

Spine - Thoracic

TMJ


MRA

MRA Abdomen

MRA Chest

MRACP Cholangiogram

MRA Head

MRA Neck/Carotid

MRA Pelvis

MRA Renal

MRA Thoracic

MRA Upper Ext

MRA Lower Ext


Nuclear Medicine

Bone Scan - 3 Phase

Bone Scan - Limited Area

Bone Scan - Whole Body

Gastric Emptying Study

HIDA Scan

HIDA Scan w/ Ejection Fraction

Liver and Spleen Scan

Liver Scan

MUGA Scan w/ Ejection

Parathyroid Sestamibi Imaging

Scintimammography/Miraluma Breast Scan

Spleen Scan Only

Testicular Scan Flow

Testicular Scan w/ Iodine

Thyroid Scan w/ Iodine

Thyroid Scan w/ Tc99

Thyroid Uptake and Scan w/ Iodine

Triple Renal Scan w/ Lasix

Triple Renal Scan w/o Lasix

Triple Renal Scan w/ Captopri


PET

PET w/CT Fusion

PET w/MRI Fusion

Limited

Skull to Mid-Thigh

Whole Body (Melanoma)

Brain

Abdomen

Abdomen & Pelvis

Abdomen & Pelvis (Renal Stone)

Chest

Extremity  Upper   Lower

Site: R   L

Facial Bones

Head

IAC / Temporal Bones

Joint    Upper    Lower

Site: R   L

Myelogram

Site:

Neck, Soft Tissue

Orbits

Pelvis

Sinus Limited   Complete

Spine - Cervical

Spine - Lumbar

Spine - Thoracic

Urogram (CT  IVP)

Virtual Colonoscopy

Other:


CTA w/3D

AAA Protocol

Aorto-Iliofemoral Runof

Abdominal Aorta / Renal /    Mesenteric

Chest

Head

Neck/Carotid

Pelvis

Upper / Lower Extremity

Site:


Bone Density

Dexa


Fluoroscopy

Barium Enema (Single Contrast)

Barium Enema w/ Air

Barium Swallow / Esophogram

Fistulogram

Loopogram

Small Bowel Series

Upper GI

Upper GI w/ Small Bowel

Venogram   Upper   Lower

Site:

Cystogram (Static)

Cystogram (Voiding)


Adenosine Dual

Isotope Stress Test


Digital Mammography

Screening   R    L    Bil

Diagnostic  R    L    Bil

Hookwire Loc      R      L

Ductogram      R      L

Other:

Ultrasound/Sono

Abdomen Complete

Abdomen Limited

Aspiration

Site

Breast      R      L

Breast Cyst Aspiration

Bypass Graft      R      L

Chest

Extremity Lower - Site

R       L

Extremity Upper - Site

R       L

Hook Wire Localization

Breast R       L

Renal (Kidney) / Aorta

Neck Soft Tissue

OB 1st Trimester < 13 wks

OB 2nd or 3rd Trimester

Pelvis Transabdominal and Transvaginal

Testicles / Scrotum

Thyroid

Other:


Doppler

Doppler Arterial Lower Ext

w/ ABI       R       L

Doppler Arterial Upper Ext

w/ ABI       R       L

Doppler Venous Lower Ext / DVT

R       L

Doppler Venous Up Ext / DVT

R       L

Doppler Abdomen

Doppler Carotid

Doppler Renal Arterial

Other:


Procedures

Arthrogram - Site

Catheter Patency

CT - Guided Aspiration

Site

CT - Guided Biopsy

Site

Hysterosalpingogram (HSG)

Lumbar Puncture  

Diagnostic  Therapeutic

Myelogram - Site

Paracentesis

PICC Line Placement

Sonohysterogram

Thoracentesis

Ultrasound Guided Aspiration

Site

Ultrasound Guided Biopsy

Site

Steroid Injection

Site

ESI - Site

Facet - Site

Lymphoscintigraphy

Site

X-ray

Abdomen KUB

Abdomen Series w/ Chest

Abdominal Flat

Abdominal Upright

AC Joints w/ Weights

AC Joints w/o Weights

Bone Age Study

Chest PA

Chest PA / Lat

Clavicle      R      L

Extremity Lower - Site

R      L

Extremity Upper - Site

R      L

Facial Complete

Facial Partial

Heel / Calcaneous

Hip w/ Pelvis      R      L

Neck Soft Tissue

Pelvis

Ribs      R      L

Sacroiliac Joint      R      L

Sacrum / Coccyx

Scoliosis Study

Shoulder      R      L

Sinus Complete 3V

Sinus Partial

Skeletal Survey

Spine - C 3V/5V/7V

Spine - L 3V/5V/7V

Spine - T 3V/5V/7V

Thoracolumbar   AP   LA


Additional Comments