tbi - large script pad 1-print - tbimri.com
TRANSCRIPT
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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
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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
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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
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72198
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72198
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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
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CTA
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70336
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72148
71550
74181
S8037
72195
73221
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73221
73218
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73721
73721
73718
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73719
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72723
73723
73720
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Right
Right
Right
Right
Right
Right
Right
Right
Right
Right
Right
Left
Left
Left
Left
Left
Left
Left
Left
Left
Left
Left
i-STATq
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72191
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73206
73706
75635
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w/o
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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
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Right Left
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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
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i-STAT
Other Impressions:
Special Instructions:
CPT CODES
CPT CODESw w & w/ow/o
CPT CODES
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Right
Right
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3D Recon
Left
Left
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Left
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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.