{"field_4b3e949":{"show_hide":"show","fire_action":"ALL","condition_created":{"cfef_logic_field_id":"field_d1f57f5","cfef_logic_field_is":"==","cfef_logic_compare_value":"MRI","_id":"9cd4bf5"}},"field_2e4d885":{"show_hide":"show","fire_action":"ALL","condition_created":{"cfef_logic_field_id":"field_d1f57f5","cfef_logic_field_is":"==","cfef_logic_compare_value":"MRI Angiography","_id":"9cd4bf5"}},"field_db5442d":{"show_hide":"show","fire_action":"ALL","condition_created":{"cfef_logic_field_id":"field_d1f57f5","cfef_logic_field_is":"==","cfef_logic_compare_value":"MRI Venography","_id":"9cd4bf5"}},"field_0a89b1f":{"show_hide":"show","fire_action":"ALL","condition_created":{"cfef_logic_field_id":"field_d1f57f5","cfef_logic_field_is":"==","cfef_logic_compare_value":"CT","_id":"9cd4bf5"}},"field_999cb09":{"show_hide":"show","fire_action":"ALL","condition_created":{"cfef_logic_field_id":"field_d1f57f5","cfef_logic_field_is":"==","cfef_logic_compare_value":"CT Angiography","_id":"9cd4bf5"}},"field_df70049":{"show_hide":"show","fire_action":"ALL","condition_created":{"cfef_logic_field_id":"field_d1f57f5","cfef_logic_field_is":"==","cfef_logic_compare_value":"PET \/ CT","_id":"9cd4bf5"}},"field_159ce2a":{"show_hide":"show","fire_action":"ALL","condition_created":{"cfef_logic_field_id":"field_d1f57f5","cfef_logic_field_is":"==","cfef_logic_compare_value":"Ultrasound","_id":"9cd4bf5"}},"field_3dd375e":{"show_hide":"show","fire_action":"ALL","condition_created":{"cfef_logic_field_id":"field_d1f57f5","cfef_logic_field_is":"==","cfef_logic_compare_value":"Vascular","_id":"9cd4bf5"}}} Patient Name Date of Birth Signs & Symptoms / ICD-10 Codes Requested Exam Date Requested Exam Time Pre-Authorization / DSN No Name Email Address Phone Fax STAT Read Call Report Send CD to Office Send CD with Patient Report Only NPI Scan MRI MRI Angiography MRI Venography CT CT Angiography PET/CT Ultrasound Vascular MRI Scan Detail w/o contrast w/wo contrast 3D Recon Arthography Radiologist may change contrast order if clinically indicated Brain Orbits IAC Pituitary TMJ Soft Tissue Neck Nasopharynx Cervical Spine Thoracic Spine Lumbar Spine T2- Iron Overload T2- Iron Overload - Abdomen T2- Iron Overload - Heart Cardiac Adenosine Perfusion Chest Breast Abdomen Elastography Brachial Plexus MRCP MRCP - with Secretin / CCK Pelvis Enterography Defecography Prostate Shoulder - Left Shoulder - Right Hip - Left Hip - Right Knee - Left Knee - Right Ankle - Left Ankle - Right Foot - Left Foot - Right MRI Angiography Head Neck (Carotid) Chest Abdomen Pelvis Extremities Lower Extremities Upper Perforated Flap (PFA) Perforated Flap (PFA) - Abdomen / Pelvis Perforated Flap (PFA) - Pelvis / Lower Extremity MRI Venography Head Abdomen Pelvis Extremities Lower Extremities Upper CT w/ contrast w/wo contrast w/o contrast 3D Recon Radiologist may change contrast order if clinically indicated Head Sinuses Orbits Temporal Bone Facial Bones Nasopharynx TMJ for Prostheses Fitting Neck Chest Lung Screening Pulmonary Embolism Study Cardiac Cardiac - Congenital Cardiac - PVI Cardiac - Calcium Scoring Only Cardiac - Non-Coronary Cardiac - TAVR Abdomen and Pelvis Abdomen Only Pelvis Only Enterography Urogram Colonography - Virtual Colonoscopy Cervical Spine Thoracic Spine Lumbar Spine CT Angiography Cardiac Cardiac w/ Calcium Score Cardiac TAVR Cardiac Add FFR Head Chest Neck Abdomen Pelvis Lower Extremity Other PET/CT Skull Base to Mid-Thigh with Vertex Whole Body (top of head to toes) Whole Body - Melanoma or Multiple Myeloma Whole Body - Other indication Brain Brain - Dementia Brain - Seizure Brain - Tumor Brain - Other indication Cardiac Cardiac - Sarcoid/Inflammation Cardiac - Rest/Stress Ultrasound add Doppler Abdominal Abdominal Complete Abdominal Limited (e.g. RUQ, LUQ, Ascites, Spleen, Appendix, Hernia) Pelvic Transabdominal Pelvic Transabdominal + Transvaginal Pelvic Transvaginal Obstetrics Infant Hips Infant Head Bladder Renal Renal for Renal Artery Stenosis Renal Transplant Liver Transplant Scrotal with Doppler Thyroid Aorta Screening Aorta Diagnostic Hysterosonography Soft Tissue Extremities Non-vascular (MSK) Extremities Non-vascular (MSK) - Upper Extremities Non-vascular (MSK) - Lower (e.g. Baker’s cyst) Extremities Non-vascular (MSK) - Right Extremities Non-vascular (MSK) - Left Vascular Soft Tissue Extremities Non-Vascular (MSK) Extremities Non-Vascular - Lower Extremity Extremities Non-Vascular - Upper Extremity Extremities Non-Vascular - Right Extremities Non-Vascular - Left Extremities Non-Vascular - Bilateral Other Send
