Overlook Medical Park
6 Tsienneto Road, Suite LL100
Derry, NH 03038
Castle Commons, Suite 103
49 Range Road
Windham, NH 03087
603.537.1363 • www.DerryImaging.com
Please bring this form and your insurance card(s) with you. Plan to arrive 10 minutes prior to any
scheduled diagnostic exams. If you arrive 15 minutes past your scheduled appointment, it may be
necessary to reschedule your exam.
Fax Order to (603) 537-1324
No appointments necessary for x-ray .
Appointment Date/Time: _________________________
Patient’s Full Name: ____________________________________________________ DOB: ______________
Ordering Provider:____________________________ Primary Care Physician: _________________________
Clinical Indication/Dx:______________________________________________________________________
________________________________________________________________________________________
ABDOMEN
CHEST/THORAX
LOW ER EXTREMITY
ULTRASOUND
1 view / KUB
Flat & Upright
Chest PA & Lat
Chest 1 view
Chest with apical lordotic
Bilat Ribs/PA CXR
Ankle
Femur
Foot
Heel
SPINES
Uni Ribs/PA CXR
Infant – Abuse
Scapula
Skeletal Series
Sternum
SC Joints
Lumbar Spine
Cervical Spine
2v c-spine/Pedi
Lumbar with oblique’s
Sacrum/coccyx
SI Joints
Thoracic Spine
R
L
R
L
R
R
R
R
L
L
L
L
Upper Abdomen
Aorta
Breast – uni or bilateral
Carotid
Knee
R
–AP Standing Knee
–Knee with Sunrise (4v)
Lower Leg
R
Toe
R
Infant Hip to Ankle
L
Extremity/non-vascular
–Upper Extremity
R
–Lower Extremity
R
Hysterosonography
OB Biophysical
OB – 1st Trimester <13 wks
OB – Complete >13 weeks
OB – Repeat FU
L
L
L
L
UPPER EXTREMITY
OB Multi-gestational
HEAD & NECK
PA Hands Arthritis
Pelvic/Gyn
PELVIS
Facial Bones
AP Feet Arthritis
Endo-Vag/OB
Pelvis – AP only
Pelvis 1hip
Pelvis & Bil Hips
3D MAMMO
Mandible
Nasal Bones
Orbits
Sinuses
Water’s (sinus) 1 view
Skull (CT Advised)
AC Joints – Bilateral
Bone Age – PA hands
Clavicle
R
Elbow
R
Finger
R
Forearm
R
L
L
L
L
Endo-Vag/Gyn
Renal
Testicular
Thyroid
Venous
–Upper Extremity
R
L
Routine Mammo
Diagnostic Mammo
Soft Tissue Neck/Adenoids
TMJ’s (MRI Advised)
Hand
Humerus
R
R
L
L
–Lower Extremity
R
L
Shoulder
Wrist
R
R
L
L
–Left
–Right
Implants
Last Mammo
R
L
–Bilateral
Y
N
BONE DENSITOMETRY
Dexa
Infant Shoulder to Wrist
CARDIOLOGY
Holter Monitor
Echocardiogram
Stress Echo
Stress Test
(treadmill max – 350 lbs)
OTHER
Patient may leave after exam.
Patient should return to physician’s office.
See prep instructions on back of this form.
Order.doc
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