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

Scan the QR Code next to preferred location with smart phone to access navigation

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