Author: Ed Cahill

EXAM REQUISITION
 X-RAY  CT MRI  US NUCLEAR MEDICINE
 PET  PET/CT  DEXA  MRA MAMMOGRAPHY
ORGAN SYSTEM(S) TO BE EXAMINED ___________________________________
Patient Name: ______________________ Date of Birth: ______________
Patient Phone: (Day) ________________ (Evening) __________________
Physician: _________________________ Phone: ___________________
Physician Signature: ___________________________________________
IV Contrast may be used at the discretion of the radiologist: YES  NO
Clinical Information/Diagnosis: ___________________________________
BUN: _____________ Creatine: _____________ Date: ______________
Are you aware if the patient has M. Tuberculosis? YES  NO
Does the patient have a pacemaker? YES  NO
Appointment Date and Time: ____________________________________
Patient Instructions:
Patient should arrive ______ minutes prior to appointment time. CT or MRI patients will be contacted by staff prior to exam for additional questions. If not contacted by 3:00 pm one day prior to CT or MRI exam, please call XXX-XXX-XXXX. Detailed information about your exam is provided by___________________________________. Thank you.
Women of childbearing ages (12-55 years) SHOULD be screened for the possibility of PREGNANCY before scheduling diagnostic, CT, and/or MRI procedures.
IMAGING CENTER: Phone (XXX) XXX-XXXX SCHEDULING: Phone (XXX) XXX-XXXX Fax (XXX) XXX-XXXX
Payment is required at the time of service unless other arrangements have been made.

[YOUR LOGO HERE]

Today’s Date: _____________
SPECIAL REQUESTS
c Send films by courier
c Send films w/patient
c Call w/appointment time
c Fax w/appointment time
c Courier w/appointment time
c Call if patient reschedules
c Other ________________
c Send copy of report to:
Dr. ___________________
PCP__________________
c Physician contact number
for urgent findings:
_____________________
c Physician after hours/
weekend #:
_____________________

[INSERT LOCATION]

[INSERT MAP HERE]

Patient Information Web Site:

[INSERT PARKING
INSTRUCTIONS]

For additional information visit:
[PLACE YOUR
WEB SITE HERE]