IU HEALTH ARNETT MEDICAL OFFICES
253 Sagamore Parkway West, West Lafayette
Imaging Services
IU HEALTH ARNETT HOSPITAL
5165 McCarty Lane, Lafayette
T: 765.448.8200
INDIANA UNIVERSITY HEALTH ARNETT
F: 765.448.8400
Name: _______________________________________________________ Appt. Date: ___________________ Appt. Time: _________________
DOB: ___________________________________
Patient Phone: ___________________________
Symptoms, Indications for Radiology Exam: _______________________________________________
Insurance Provider: _______________________________________________
Pre-Certification #(Please fax copy of card): ________________
Special Instructions and Prep: ______________________________________________________________________________________________
MRI
CT
HEAD & NECK
___ Brain
___ Orbits
___ Pituitary
___ Soft Tissue Neck
___ TMJ
HEAD & NECK
___ Brain
___ Sinus
___ Soft Tissue Neck
___ Temporal Bones/IACs
___ Orbits
SPINE
___ Cervical
___ Thoracic
___ Lumbar
SPINE
___ Cervical
___ Thoracic
___ Lumbar
BODY
___ Abdomen
___ Breast
___ Chest
___ Pelvis
___ Ankle
___ Elbow
___ Hand
___ Hip
___ Knee ___ Shoulder ___ Wrist
BODY
___ Chest
___ Abdomen
___ Abdomen Enterography
___ Pelvis
___ Pelvis Enterography
___ Extremity (specify)
__________
___ No Contrast
___ With IV Contrast
___ With and W/O IV Contrast
L
L
L
L
L
L
L
R
R
R
R
R
R
R
Bilat
Bilat
Bilat
Bilat
Bilat
Bilat
Bilat
MRA
___ Abdomen/Renals
___ Chest
___ Head/Brain
___ Lower Extremities
___ Neck
___ Pelvis
OTHER MRI
___ Other (specify):
_________________
FLUOROSCOPY
___ Colon w/Air
___ Cystogram
___ Esophogram
___ Hysterosalpingogram
___ IVP
___ Small Bowel Series
___ Upper GI w/Air
___ VCUG
___ Video Swallow Study
___ Other (specify):
_________________
___ No Contrast
___ With IV Contrast
___ With and W/O IV Contrast
CTA
___ Abdomen
___ Carotids/Neck
___ Chest
___ Pelvis
PROCEDURES
___ CT Myelogram
___ CT Biopsy/Drain of:
________________
OTHER CT
___ Other (specify):
_________________
SCREENINGS
___ $49 Lung Scans
___ $49 Heart Scans MAMMOGRAPHY
___ Screening Mammogram
___ Diagnostic Mammogram
L R Bilat
___ Magnification/Spot views
L R Bilat
___ Breast Ultrasound L R Bilat
___ Core Biopsy
L R Bilat
___ Stereo Biopsy
L R Bilat
___ Other (specify):
_________________
NUCLEAR MEDICINE
INTERVENTIONAL
___ Bone Scan
___ limited of ________
___ whole body
___ 3 phase of ________
___ Gallbladder
___ Gastric Empyting
___ Lung V/Q
___ MUGA
___ Parathyroid
___ Renal with Lasix
___ Renal w/o Lasix
___ Thyroid I-123
___ Thyroid I-131
___ Other (specify):
_________________
___ Angiogram of: __________
___ Arthrogram of: __________
___ Biopsy of: __________
___ EVLT of: __________
___ Myelogram of: __________
___ Phlebectomy of: __________
___ PICC Line/Port of: __________
___ Venogram of: __________
___ Other (specify):
_________________
GENERAL RADIOLOGY
CHEST
___ Chest PA Only
___ Chest PA & LAT
___ Chest PA & LAT with Obliques
CARDIAC
___ Treadmill Stress
___ Lexiscan Stress
ULTRASOUND
BODY
___ Abdomen
___ Aorta
___ Carotid
___ Pelvic Limited
___ Pelvic Complete
___ Renal
___ Renal Doppler
___ Right Upper Quadrant
(Gallbladder, Liver)
___ Transvaginal
___ Scrotal
___ Thyroid
___ Arterial Duplex of: __________
___ Venous Duplex of: __________
___ Vein Mapping of: ____________
___ Extremity (specify):
___________
OBSTETRICAL
___ < 14 weeks
___ > 14 weeks
___ > 20 weeks
PROCEDURES
___ Liver Biopsy
___ Paracentesis
___ Thoracentesis
___ Thyroid Biopsy
OTHER ULTRASOUND
___ Other (specify):
_________________
BODY/EXTREMITIES
___ Facial Bones
___ KUB
___ Neck Soft Tissue
___ Pelvis
___ Sinus
___ Skull
___ Ankle L R Bilat
___ Elbow L R Bilat
___ Femur L R Bilat
___ Finger L R Bilat
___ Foot L R Bilat
___ Hand L R Bilat
___ Hip L R Bilat
___ Knee L R Bilat
___ Ribs w/PA Chest L R Bilat
___ Shoulder L R Bilat
___ Wrist L R Bilat
___ Specific Views: ___________
SPINE
___ Cervical Spine
___ Thoracic Spine
___ Lumbar Spine
___ With Flex/Extension
___ With Obliques
OTHER GENERAL RADIOLOGY
___ Other (specify):
_________________
PET/CT
___ Indication: __________
BONE DENSITOMETRY
___ Axial Skeleton
___ Peripheral
Physician’s Name: __________________________________________________
(PLEASE PRINT)
Physician’s Signature: _______________________________________________
Physician’s Phone #: ________________________________________________
Please fax report to: ______________________________
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