McLaren Northern Michigan X-Ray Order Form

McLaren Northern Michigan X-Ray Order Form

Patient's Name Last:

First:

Is there any chance that the patient is pregnant? Y N Insurance Information

MI:

STAT READ Cheboygan Patient Phone Daytime Phone:

Date of Birth Petoskey LTPC

Male Female Gaylord

Cell:

Please Complete/Print/Sign and Fax to Central Scheduling: Fax 231.487.7920-Tel 231.487.3100-Toll Free 866.487.3100 Reason for Exam/Signs and Symptoms:

ICD-10 Code(s):

CHEST

Chest 2v (PA & lat) Chest 1v (AP or PA) Chest 2v w/ Apical Lordotic Chest 4v (PA & lat w/obliques) Chest Insp & Exp w Lateral Ribs Right w PA Chest Ribs Left w PA Chest Ribs Bilateral w PA Chest Decubitus Chest L R Sternum

ABDOMEN

AP Single View (KUB)

AP & Upright/Decubitus Acute Abd w 1v Chest VP Shunt Evaluation Babygram Other (Specify in free text box) Free Text Box: (include any special

instructions)

UPPER EXTREMITY

Finger(s) 1 2 3 4 5 L R

Hand

L R

Bone Age

L R

Wrist

L R

Wrist with Scaphoid View

L R

Forearm

L R

Elbow Survey (AP & lat)

L R

Elbow Trauma (4 views)

L R

Humerus

L R

Shoulder

L R

Scapula

L R

LOWER EXTREMITY

Toe(s) 1 2 3 4 5 L R

Foot

L R

Calcaneus (Heel)

L R

Ankle Survey (2 views)

L R

Ankle Complete (4 views)

L R

Tib-Fib

L R

Knee Survey (AP & lat only) L R

Knee 3 Views

L R

Knee Complete (4 views)

L R

Femur

L R

Hip Complete

L R

SPINE

Cervical AP & Lat (Min. 4 views

if Swimmers/Fuchs view is needed to see C-1 / C-7)

Cervical AP & Lat Only (post-op)

Cervical AP & Lat w Obliques

Cervical Comp (w obl, flex & ext)

Thoracic w Swimmers View

Thoraco-Lumbar Spine

Lumbar AP & Lat Only (post-op) Lumbar Lateral (Flex & Ext Only) Lumbar Min. 4 Views

(includes AP, AP sacrum, lat & spot)

Lumbar AP & Lat w Obliques

Clavicle AC Joints Infant Upper (Under 18 mos) Other (Specify in free text box)

HEAD

Skull Complete

L R L R

Pelvis

Lumbar Complete w Obliques and Flex & Ext

SI Joints

Sacrum/Coccyx

Infant Lower (Under 18 mos) L R Neck Soft Tissue AP & Lat

Other (Specify in free text box)

Other (Specify in free text box)

To be Scheduled: Please Call 231.487.3100

Scoliosis Standing

Leg Length

L R

Cystogram

Lap Band Adjustment

Voiding Cystogram (VCUG)

Bone Survey Complete

Skull PA & Lateral

Hysterosalpingogram

T-Tube Injection

Skull for Pressure Valve Check

IVP w Tomograms

Sniff Test

Facial Bones Complete

Nephrostogram

Arthrogram No CT/MRI

Mandible Orthopantogram (Panorex) Nasal Bones

Hip Injection

L R

(please specify medications in free text box)

Lumbar Puncture Under Fluoro

Shoulder Wrist L R Barium Enema Single

Contrast Barium Enema Air Contrast

Orbits / Pre MRI / Foreign Body Orbits Trauma Sinuses ? Waters View Only Sinuses Complete Other (Specify in free text box)

Cervical Myelogram w CT

Thoracic Myelogram w CT

Lumbar Myelogram w CT Therapeutic Spinal Injection Procedure

In "Free Text Box", please indicate type of injection, laterality, levels or other important clinical information. Consultation with Radiologist recommended.

RFN (Please specify levels in free text)

TMJ X-Ray with tomography

Water Soluble Enema Enema via Colostomy Esophagram (Barium Swallow) Small Bowel Series Upper GI Air Contrast (Routine) Upper GI Single Contrast Video Swallow Other (Specify in free text box)

Form Filled out by: Today's Date & Time:

Physician signature: _

Office Phone: Exam Date & Time:

(Sign after printing)

MNM 721.293 - Rev: 3/19/2018

*F721293*

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