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Order Details
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Patient's name (Last, First):
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DOB:
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Pre-Authorization # / Pre-Notification #:
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Referring Physician's Name:
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MRI / MRA
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Orbits X-Ray based on patient history
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With contrast?
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BUN:
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CREAT:
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Date of lab work:
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Select those that apply:
• • •
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MRA needed?
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If yes, specify:
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Extremity? (specify):
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CT / CTA
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With contrast?
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CREAT:
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BUN:
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Date of lab work:
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Select those that apply:
• • •
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Extremity? (specify):
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Spine with 3D? (specify):
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Spine without 3D? (specify):
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CTA? (specify):
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Ultrasound
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Select those that apply:
• • •
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Soft Tissue/Other? (specify):
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Venous Duplex (R/O DVT)? (specify upper/lower, R, L, Bil, and Hip, Right, Left Bilateral):
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3D CT? (specify):
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Coronary CTA? (specify):
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Diagnostic X-Ray
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Chest X-Ray?
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Other Exam? (specify):
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Mammography
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If additional imaging and ultrasound are needed the same day as the appointment, treat and evaluate
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Select those that apply:
• • •
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Breast Biopsy
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Ultrasound Guided?
• • •
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Stereotactic?
• • •
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MRI Guided?
• • •
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DEXA
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Bone Density Scan needed?
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Other
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Other Examinations Requested:
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Clinical Dx / Relevant Clinical Findings:
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Order may be modified according to department written protocol including the administration of contrast
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If no, specify:
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Results
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Fax results to: (646) 871-6882
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Provider Electronic Signature:
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Electronic Signature
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