w/o w w & w/o

70450

70490

70480

70486

70450

70490

72125

72128

72131

71250

74150

74176

72192

73200

73700

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

70470

70492

70482

70488

70470

70492

72127

72130

72133

71270

74170

74178

72194

73202

73702

76376

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

Patient

Appointment Date & Time

Exam Requested

Physician Name

Physician Signature

7800 66TH ST. North #106 • Pinellas Park, FL 33781

Tel: (727) 545.9MRI (9674) • Fax (727) 545.9454

SERVICE • QUALITY • COMFORT

TAMPA BAY IMAGING

MRI

Brain

Neck

Abdomen

Renal

Pelvis

Other

CT

q

q

q

q

q

q

Head w/3D (Circle of Willis)

Neck Contrast w/3D (Carotids)

Chest - Pulmonary Embolism w/3D

Chest - Thoracic Aorta w/3D

Abdominal Aorta w/3D

Pelvis w/3D

Abdomen w/3D

Upper Extremity w/3D

Lower Extremity w/3D

Iliofemoral Runoff w/3D

q

q

q

q

q

q

q

q

q

q

Brain (Head)

Pituitary

Orbits

Sinuses

Temporal Bones

Neck-Soft Tissue

Cervical Spine

Thoracic Spine

Lumbar Spine

Chest

Pelvis

Upper Extremity

Abdomen

Abd / Pel

Lower Extremity

Other

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

70544

70547

74185

74185

72198

q

q

q

q

q

70545

70548

74185

74185

72198

q

q

q

q

q

70546

70549

74185

74185

72198

q

q

q

q

q

w/o w w & w/o

MRA

Brain

Orbits

IACs

Pituitary

Sinuses

TMJ

Neck-Soft Tissue (palpable mass)

Brachial Plexus

Cervical Spine

Thoracic Spine

Lumbar Spine

Chest

MRCP

Pelvis

Shoulder

Elbow

Wrist

Hand

Hip

Femur/Thigh

Tib/Fib

Knee

Abdomen

Ankle

Foot

Other

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

CTA

70551

70540

70540

70551

70540

70336

70540

71550

72141

72146

72148

71550

74181

S8037

72195

73221

73221

73221

73218

73721

73718

73718

73721

73721

73718

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

70552

70542

70542

70552

70542

70336

70542

71551

72142

72147

72149

71551

74182

S8037

72196

73222

73222

73222

73219

73722

73719

73719

73722

73722

73719

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

70553

70543

70543

70553

70543

70336

70543

71552

72156

72157

72158

71552

74183

S8037

72197

73223

73223

73223

73220

73723

73720

73720

72723

73723

73720

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

Right

Right

Right

Right

Right

Right

Right

Right

Right

Right

Right

Left

Left

Left

Left

Left

Left

Left

Left

Left

Left

Left

i-STATq

70496

70498

71275

71275

75635

72191

74175

73206

73706

75635

q

q

q

q

q

q

q

q

q

q

w/o

82565q

DIRECTIONS: Please see reverse side for maps and directions to Tampa Bay Imaging as well as important information about your exam!

X-RAYAbdomen (KUB)

Ankle - 2 Views

Ankle - Complete

Cervical - 2 Views

Cervical - 4 Views

Cervical -Complete

Chest

Clavicle

Coccyx

Elbow - 2 Views

Elbow - Complete

Facial Bones

Femur

Finger - Digit ______

Foot - 2 Views

Foot - Complete

Forearm

Hand

Hip Unilateral One View

Hip

Knee - 2 Views

Knee - 3 Views

Other

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

Right Left

q

q

Knees - 4 Views

Lumbar

Lumbar - Complete

Mandible - (PA & LAT)

Mandible - Complete

Nasal Bone - Complete

Orbits

Pelvis

Ribs

Sacral Joint

Sacrum

Scapula

Shoulder

Shoulder - 2 Views

Sinuses - Waters View

Sinuses - Complete

Skull

Tibia / Fibula

Thoracic - 2 Views

Thoracic - 3 Views

Wrist - 2 Views

Wrist - Complete

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

i-STAT

Other Impressions:

Special Instructions:

CPT CODES

CPT CODESw w & w/ow/o

CPT CODES

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

q

Right

Right

q

q

70460

70491

70481

70487

70460

70491

72126

72129

72132

71260

74160

74177

72193

73201

73701

3D Recon

Left

Left

q

q

Right

Right

q

q

Left

Left

q

q

WHAT TO EXPECT FOR YOUR EXAM?•• MRI utilizes safe radio waves and magnetic field to generate a detailed, clear image processed by a computer. There is no radiation associated with an MRI exam.

MRI is generally painless and causes no known side effects. MRI cannot be used on patients with pacemakers, cerebral aneurysm clips,or some other medical devices. Also, MRI is not recommended for pregnant women.

• CT imaging combines special x-ray equipment with sophisticated computers to produce multiple images or pictures of the inside of the body. • For CT examinations, please refrain from eating (NPO) at least 4 hours to your appointment, especially if a contrast material will be used for your exam.• Your diagnostic procedure will be explained to you by a trained staff member before your examination begins. During this time, you should ask any questions you may have.

You may also be asked to change into a patient gown.• On the day of your scheduled examination, please remove makeup from your skin and remove any metal objects in your possession. A secured locker will be provided.• You will be asked to lie flat on a comfortably designed, padded table, which will be slid into position for examination. Once the examination begins, you should relax and

remain as still as possible.• After the examination is complete, you will be given the opportunity to retrieve your personal possessions. At this time, you may return to your normal activities. • Results of your examination are generally produced within 24 hours and are sent to your physician. Your physician will then contact you to schedule an appointment to

discuss the results with you.

There is no preparation for an MRI exam.

DIRECTIONS

From North:Take US 19 South to 66th Street exit and continue South on 66th St. Turn right on 78th Ave., and make an immediate right into the

Pinellas Professional Center.

From South:Take 66th Street North to 78th Ave, make left. Make an immediate right into the Pinellas Professional Center.

DIRECTIONS

From North:Dale Mabry to Dr. MLK. Make left. Located in the Bank of

America building. One block east of Habana.

From South:Take Dale Mabry North to Dr. MLK. Make right. Located in the

Bank of America building, one block east of Habana.

Belc

her

Rd

Tampa Bay Imaging7800 - 66TH ST. N.

Suite 106(727) 545-9674

66th

St

78th Ave

N

S

EW

Park Blvd

PINELLASTAMPA

Dale

Mabry

Tampa Bay Imaging2700 - MLK Jr Blvd.

Suite 130(Bank of America Bldg.)

(813) 386-3674

Habana A

ve.

MLK Jr. Blvd.

N

S

EW

Columbus

Hillsborough Ave.

I-275

Arm

ern

ia A

ve.