Central Scheduling PHONE: 704-384-7226...Central Scheduling PHONE: 704-384-7226 Scheduling Fax:...

PHYSICIAN SIGNATURE:

RADIOGRAPHIC STUDIES

PET / CT

FLUOROSCOPY

ULTRASOUND STUDIES

INTERVENTIONAL RADIOLOGY

Patient to Call Call Patient to Schedule--Patient Phone #_________________________Cell:___________________

Insurance Carrier:________________________________________Auth. #__________________________Auth. Facility__________________________

DOB________________

Diagnosis/Signs/Symptoms____________________________________

NUCLEAR MEDICINE

LUMBAR PUNCTURE

MRI CT

MRI CT

MRI CT

MRI CT

MRI CT

MRI CT

MRI CT

MRI CT

Central Scheduling PHONE: 704-384-7226Scheduling Fax: Imaging Center: 704-384-8511 / Hospital: 704-316-9327

HEAD/NECKHeadBrain Brain Lab Protocol Seizure Protocol Functional IACPituitaryOrbitsNeck (Soft Tissue)TMJ

BODYChestBrachial PlexusAbdomenPelvis Bony Female MaleMRCPBreast R L BBreast BiopsyProstateAdrenalKidneysEnterography Other________________

SPINECervicalThoracicLumbarSacrum Arthrogram

Joint__________________CARDIAC

Morphology/Function+ Stress

MRI ANGIOGRAMHeadNeckChestAbdomenRunoff ________________________________________________

SedationGENERAL*

*only at PH

Contrast: With & Without Without Rad Discretion

HEAD/NECKHead / BrainTemporal BoneOrbitsNeck (Soft Tissue)Facial BonesSinusSinus Mini

SPINECervicalThoracicLumbar

CT ScreeningCT Cardiac ScoringCT Lung Screening

CT BiopsyLungAbdominalBoneCT Myelogram

CervicalThoracicLumbar

FNAFNAFNA

CoreCoreCore

CARDIACCT Coronary AngioPulmonary VeinsCongenital

BODYChestChest - HIGH RESAbdomenPelvisAbd & PelvisChest/Abd/PelvisCT EnterographyRenalRenal-Stone ProtocolCT UrogramAdrenalChest/Abdomen/PelvisCT Colonography

CT ANGIOGRAMHead / BrainNeckThoracic / ChestPE ProtocolAbdomen / RenalAbdomen / PelvisMesentericUpper Extremity R LLower Extremity R LRunoff_____________

Contrast: With Without Rad Discretion

Bone Scan Bone Scan w/ SPECT3 Phase Bone Scan3 Phase Bone Scan w/ SPECTGastric Emptying ScanHIDA Scan with EFV/Q ScanRenal ScanMUGA (Gated Heart)Nuclear Stress TestI-131 TherapyI-131 Post-Therapy Scan

I-131 Whole Body ScanI-131 Thyrogen Stimulated TherapyI-131 Thyrogen Stimulated Whole Body ScanThyroid Scan OnlyThyroid Uptake OnlyThyroid Uptake & ScanI-123/Sestamibi Parathyroid SPECTParathyroid ScanParathyroid SPECTOther_____________________________________

w/UGI

Prior Imaging:When?_____________________

Where?_____________________

LAP BAND ADJUSTMENT

MBS w/ VIDEO

HIP INJ/ASPIRATIONHSG

#:_______________________________________________________________________________________________________________________________________________________________________________________

DEXA - Bone DensitometryX-Ray_______________________________________

AbdomenAbdomen / Pelvis/EndovagPelvis / EndovagPediatric Patient / Pelvis USLiverRUQ / GallbladderAortaCarotidsCarotid IMTTranscranial

ThyroidScrotal w/ DopplerProstateHipsNeck-soft tissueSoft Tissue_______Renal___________Prostate BiopsyPSA Level____DVT Upper R L BDVT Lower R L B

Arterial Doppler Upper R L BArterial Doppler Lower R L BVenous Mapping R L BRenal Artery DopplerInfant SpineThoracentesisParacentesisBiopsy Thyroid Liver Renal

Skull Base to ThighWhole BodyBrainCardiac ViablityF18 Bone Scan

3-D Reconstruction

w/AIR w/o AIR referring Rad

RT LT

Other:_______________________

________________________________________________________________

Novant Health ImagingBreast Center704.384.50001718 E. 4th St.Charlotte, NC 28204Services: Digital Screening and Diagnostic Mammography,Needle Localization, Biopsies, Sentinel Node Injections, DEXAand Breast Sonography

Novant Health ImagingGastonia704.862.7188920 Cox Rd., Ste. 101Gastonia, NC 28054Services: CT, Ultrasound, High Field MRI

Novant Health ImagingMooresville704.662.8580118 Gateway Blvd., Ste. EMooresville, NC 28117Services: CT, High Field MRI

Novant Health ImagingSteele Creek 704.316.288013557 Steelecroft Pkwy., Ste. 1100Charlotte, NC 28278Services: CT, High Field MRI, Ultrasound and X-Ray

Novant Health ImagingSouthpark704.362.84446324 Fairview Rd., Ste. 120Charlotte, NC 28210Services: X-Ray, CT, Ultrasound and Wide Open Bore

Novant HealthPresbyterian Medical Center704.384.4056200 Hawthorne Ln.Charlotte, NC 28204Services: MRI (3T and 1.5T), fMRI, CT, PET, X-Ray,Fluoroscopy, Ultrasound, Nuclear Medicine andInterventional Radiology Procedures

Novant HealthMatthews Medical Center704.384.67501500 Matthews Township Pkwy.Matthews, NC 28105Services: CT, Ultrasound, MRI, X-Ray, Fluoroscopic Exams,PET, Nuclear Medicine, Digital Screeningand Diagnostic Mammography

Novant Health Charlotte Orthopedic Hospital704.316.14111901 Randolph Rd.Charlotte, NC 28207Services: X-Ray, Orthopaedic Special Procedures such asMyelograms, Spinal/Epidural Injections, Nerve Root/Joint Blocks,Arthrograms, Joint Aspirations, Discograms, Wrist Videography,MRI and CT

Novant Health ImagingCabarrus704.262.9885925 Bradley St. NEConcord, NC 28025Services: High Field MRI, Open MRI and CT

Novant Health ImagingRock Hill803.547.1100175 Amendment Ave., Ste. 101Rock Hill, SC 29732Services: High Field MRI, CT, Ultrasound, DEXA, X-Rayand Arthrogram

Novant HealthHuntersville Medical Center704.316.376410030 Gilead Rd.Huntersville, NC 28078Services: CT, Ultrasound, MRI, X-Ray, Mammography,Fluoroscopic Exams, PET and Nuclear Medicine

Novant Health ImagingBallantyne704.384.189014215 Ballantyne Corporate Pl., Ste. 140Charlotte, NC 28277Services: CT, Ultrasound, High Field MRI, X-Ray,DEXA and Digital Screening Mammography

Novant Health ImagingMonroe*704.316.11802000 Wellness Blvd., Ste. 110Monroe, NC 28110Services: CT, Ultrasound, High Field MRI, X-Rayand Digital Screening Mammography

Novant Health ImagingMuseum*704.384.71402900 Randolph Rd.Charlotte, NC 28211Services: CT, Ultrasound, High Field MRI, X-Ray,Fluoroscopic Exams, Digital Screening Mammographyand IVP

Novant Health ImagingUniversity*704.384.15808401 Medical Plaza Dr., Ste. 110Charlotte, NC 28262Services: CT, Ultrasound, High Field MRI, X-Ray, DEXA,Fluoroscopic Exams and Digital Screening Mammography

Novant HealthBreast Center704.316.553510030 Gilead Rd., Ste. 330Huntersville, NC 28078Services: Digital Screening and Diagnostic Mammography

* indicates A Department of Novant Health Presbyterian Medical Center

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Breast Center” (I know it is the same as above they want it that way)