SALINAS VALLEY

IMAGINGMEDICAL IMAGING E X P E R T S

TAX ID #941723382

D 559 Abbott Street, Salinas • 831-775-5200 • Fax 831-796-3891 (CT, US, X-RAY, OPEN MRI)

D 1326 Natividad Road, Ste.E, Salinas • 831-796-3774 • Fax 831-424-1857 (X-RAY)

[J 26542 Carmel Rancho Blvd. Carmel • 831-625-7255 • Fax 831-625-7250 (MRI & US)

D Primecare Medical Group • 355 Abbott St. • 831 -751 -7070

Please fax completed form, copy of insurance card, pertaining history and physical to Salinas or Carmel location selected above.

CT US X-RAY REQUESTPatient: Last Name. First (printed) Date of Birth

Special Instructions

LJ STAT PHONE Call Back Number

Referring Physician / Signature

Date and Time of Appointment

DIAGNOSIS / HISTORY

CT (contrast: IV D Oral D P.R. D)

IV CONTRAST STUDIES ONLY (labs required if diabetic / kidney insuffiency / ove

D Head with & w/o Contrast D Sinuses w/o ContrastD Head w/o Contrast D Neck with ContrastD Orbit / IAC / Sella / Post D Neck w/o Contrast

Fossa with & w/o Contrast D Cardiac Angio with ConlD Temporal Bone D Cardiac Calcium Scorin

D Chest with ContrastD Chest w/o Contrast

D Pain Injection n chest High Resolution

CTA (circle): intracranial (cow)

USAbdomen (select)D Aorta n Kidneys (renal)D GB n PancreasD Liver D Spleen

D Liver Doppler (Portal Flow)D Renal Artery Doppler (HTN)D SMA DopplerD Abdominal Wall (Hernia)D RLQ (Appendix)

Doppler if indicated

X-RAYD Abdomen One ViewD Abdomen Sup & UprightD Abd Sup, Upright, DecubD Abdomen for FIB childD Acromio-Clavicular JointsD Ankle CompleteD Ankle LimitedD Cervical Spine CompleteD Cervical Spine Lat OnlyD Cervical Spine AP & LatD Cerv Sp Lat Flex & ExtD Chest One ViewD Chest Two ViewD Chest with ObliquesD Chest 4 views AsbestosisD ClavicleD Elbow CompleteD Elbow LimitedD Facial Bones CompleteD Facial Bones Limited

Fluoro & Other ProceduresD Colon (Barium Enema)D Colon Air ContrastD EsophagramD Myelogram (w/CT)

Q STAT FAX Q SendCC

CC:

Request Date

Patient Telephone Number

) w/Patient

Physician Telephone Number

Name of Insurance Company / Prior Authorization Number

r70) DIABETIC DYES D NO GLUCOPHAGE

D Myelogram (w/Fluoro)D Abdomen with ContrastD Abdomen w/o Contrast

rast n Abd-Pelvis with Contrast3 D Abd-Pelvis w/o Contrast

D Abd-Pelv. Stone ProtocoD Pelvis with ContrastD Pelvis w/o ContrastD CT Urography

• cerv carotids • upr ext • thor aorta • abd aorta • abd aorta w/runoff •

Carotid Doppler (select below) D OB NT (12-13 weeks) Doppler if indie,D Bilateral D Left D Right D OB Under 14 weeks Doppler if indict

D OB Detailed Over 18 Wks Doppler HD Temporal Artery Doppler D OB Limited/Follow-up Doppler if indie

D OB Multiple Gestations Doppler if MINewborn (select) n Fetal Biophysical ProfileD Head D Hips D Pylorus D Spine g Pelvis Complete Doppler it indicated

Soft Tissue Maw (select) ° ̂ (V'hyroid) D L D RD Leg D Arm D Scrotum Doppler if indicatedD Neck D Back D Other n • i_,i ̂ ,_.i /^ — -.^ n i n D

DYES DNO LAB LOCATION

D Cervical Sp w/o ContrastD Lumbar Sp w/o ContrastD Upper Ext with Contrast R / LD Upper Ext w/o Contrast R / LD Lower Ext with Contrast R / LD Lower Ext w/o Contrast R / LD Bone DensityD Leg Length

renals • pelvic • periph runoff • Iwr ext

'ted Arterial Doppler (PAD. Screening)

"ed D Complete Legs w/ABInd:ca,ed n AB| Qn| n Arms

tied

•ated Graft Eval- D Le9 E Arrn D L D R

Venous Eval. for DVTO Leg D Arm D L D R

Venous Insufficiency D L D RD Diagnosis D Mapping D Ablation

Other

D RIGHT DLEFT D BILATERAL

D Femur D Lumbar Spine Complete D Scoliosis One ViewD Finger D Lumbar Spine AP/Lateral D Scoliosis Two ViewsD Foot Complete D Lumbar Sp Incl Flex & Extn D Sella TurcicaD Foot Limited D L/S Sp Lat F & E Upright D Shoulder CompleteD Forearm D Mandible Complete D Shoulder LimitedD Hand Complete D Mastoids D Skeletal SurveyD Hand Limited D Myeloma Bone Survey D Skull CompleteD Hands/Wrists Arth 1 Vw D Nasal Bones D Skull LimitedD Hands/Wrists Bn Age 1 V D Orbits Complete D Soft Tissue NeckD Hip Bilat with AP Pelvis D Orbits Ltd for F/B D Sternoclavicular JointsD Hip Unilateral 2 Views D Os Calcis (Heel) D SternumD Hip Unilateral 1 View D Paranasal Sinuses Comp D Thoracic Spine 3 VwsD Hip-Infant/Child D Paranasal Sinuses Waters D Thoraco-Lumbar SpineD Hip-Pelvis Incl Lwr Ext-Child D Pelvis AP D Tibia & FibulaD Humerus D Pelvis AP/Lat Seed Plcmt D TMJ'sD Knee Complete CD Ribs Bilat w/PA Chest D Toe(s)D Knee Limited D Ribs Unilat w/PA Chest D Upper Ext Inft/ChildD Knee with Patella D Sacro-lliac Joints Compl D Wrist CompleteD Knee AP/Lat Standing D Sacro-lliac Joints AP D Wrist LimitedD Knees Bilat AP Standing D Sacrum & CoccyxD Lower Ext Infant/Child D Scapula

D Upper G.I. SeriesD G.I. & Small BowelD Small Bowel OnlyD Hysterosalpingogram

D IVP with TomosD IVP w/o TomosD Loopogram / Heal ConduitD Cholangiogram (T-tube)

D Arthrogram (w/MRI)Site

PLEASE BRING THIS FORM WITH YOU ON THE DAY OF YOUR EXAM (see back)

SPECIAL INSTRUCTIONS

COMPUTERIZED TOMOGRAPHY- CONTRAST EXAMS

Do not eat or drink anything for three hours prior to examination.Head or Sinus CT scan: No earrings or hairpins (please remove prior to appointment).

Labs required for kidney insuffiency, diabetics or any patients over 70 years of age.

ULTRASONOGRAPHY

AORTA, GALLBLADDER, LIVER, PANCREAS AND/OR SPLEEN: Do not eat or drinkafter the evening meal (8PM), water ok until bedtime. Nothing to eat or drink (including water)on the morning of your examination.

DOPPLER OF ABDOMEN: Take two (2) antigas tablets (Maalox, Mylanta, etc.) the eveningbefore the exam, and two (2) tablets the morning of the exam. Do not eat or drink (including water)on the morning of your examination.

KIDNEY: One hour before appointment, please empty bladder; immediately drink two (2) largeglasses (32 ounces) of water. You may go to the bathroom, unless instructed otherwise.

OBSTETRICAL OR BLADDER: One hour before appointment, please empty bladder; immediatelydrink 24 ounces of water. Do not empty bladder, keep bladder full for the appointment.

PELVIS: One hour before appointment, please empty bladder; immediately drink two (2) largeglasses (32 ounces) of water. Do not empty bladder, keep your bladder full for the appointment.(IT IS IMPORTANT THAT YOU FINISH DRINKING ONE HOUR PRIOR TO EXAM)

RADIOLOGY- FLUORO & OTHER PROCEDURES

BARIUM ENEMA: Please contact Salinas Valley Imaging Center at least 48 hours prior to your examfor fasting instructions and to pick up your cleansing kit (831-775-5200).

UPPER G.I. SERIES (with or without small bowel): Nothing to eat or drink after the evening meal (8PM),water ok until bedtime. On the morning of your appointment: Nothing to eat or drink (including water) -No smoking - No gum chewing - Do not brush your teeth. Take a mild laxative or use a cleansingenema the day following the examination; the barium you drink during the examinationmay cause constipation.EXCRETORY UROGRAM (IVP): On the night before your exam, one hour before a light eveningmeal, take a laxative (please contact your physician for a laxative recommendation). Nothing toeat or drink (including water) on the morning of your examination.

PLEASE DO NOT WEAR PERFUME OR COLOGNE TO YOUR APPOINTMENT

CARMEL VALLEY ROAI1

Carmel RanchoShopping Center

Coastal Valley Imagingof Carmel

(26542 Carmel Rancho Boulevard)

831-625-7255 831-775-5200 831-796-3774SALINAS PRESS FORM #200