Galveston

301 University Boulevard

Galveston, Texas, 77555-0709
Phone 409.772.7150
Fax 409.747.2850

Victory Lakes
2240 Gulf Freeway South, Suite 1.204
League City, Texas 77573
Phone 832.505.1400
Fax 281.309.0259

Radiology Imaging Centers

OUTPATIENT DIAGNOSTIC ORDER FORM
Patient Name

Date of Birth

Home Phone

Work Phone

Cell Phone

Insurance Company Name

Insurance Company Phone #

Policy #

Group #

PreCert # / Auth

Subscribers Name

Date of Birth

Relationship to Patient

Subscribers Employer Name

Please indicate exam with an X and write in region of interest.

Mark
an X

MRI
Head
Region:
With & Without
Contrast: Without
Neck
With & Without
Contrast: Without
Right
Left Bilateral
Extremity Upper
Region:
With & Without
Contrast: Without
Right
Left Bilateral
Extremity Lower
Region:
With & Without
Contrast: Without
Spine
Region:
With & Without
Contrast: Without
Pelvis
With & Without
Contrast: Without
Abdomen
With & Without
Contrast: Without
ABD/Pelvis
With & Without
Contrast: Without
Cardiac MRI
With & Without
Contrast: Without
Chest
With & Without
Contrast: Without
Bilateral Breast MRI
With & Without
Contrast: Without

MRA

Without
With & Without
Head
Without
With & Without
Neck
With & Without
Abdomen Without
Without
With & Without
Chest
With & Without
Lower extremity Without

CT
Head
Region:
Contrast: Without With With & Without

Mark
an X

CT (continued)

Sinus
Contrast: Without
Soft Tissue Neck
Contrast: Without
Chest
Contrast: Without
ABD/Pelvis
Contrast: Without
Spine
Region:
Contrast: Without
Other:

With With & Without

With With & Without
With With & Without

Mark
an X

Digital Mammogram (continued)

Bilateral Breast Ultrasound
Unilateral Breast Ultrasound

Procedures

Stereotactic Breast Biopsy

Ultrasound - Guided Breast Biopsy
Ultrasound FNA
Galactogram or Ductogram

With With & Without

With With & Without

Nuclear Medicine

Please Fill In Study:

CT Angiography

Angio Head
Angio Neck
Angio Chest
Angio Abdomen/Pelvis
Cardiac CT
Other:

Ultrasound
Abdomen
Abdomen
Abdomen
Abdomen

Complete
Complete with Doppler
Limited
Limited with Doppler

BONE DENSITY
Dexa

DIAGNOSTIC RADIOLOGY/ X-RAY

Please Fill In Study:

Pelvic with Transvaginal

FLUOROSCOPY:
Please Fill In Study:

Testicular/ Scrotum
Thyroid
Renal Limited
Transplant Kidney
Extremities
1st Trimester Pregnancy(<14Weeks)

Digital Mammogram

Screening Mammogram

INTERVENTIONAL RADIOLOGY
Please Fill In Study:

Diagnostic Bilateral Mammogram

*** Breast Ultrasound if clinically indicated

Diagnostic Unilateral Mammogram R L

*** Breast Ultrasound if clinically indicated

OTHER EXAM REQUESTED:

Allergies:
Reason for exam:

Pregnant

Yes

No
For IV Contrast Studies
Creatinine:
Date of Creatinine:

Radiologist Recommendations:
IF PATIENT ID CARD OR LABEL IS UNAVAILABLE, WRITE PATIENT INFORMATION BELOW

DIAGNOSIS or ICD9 CODE:

DATE:

PHYSICIAN
SIGNATURE:

PT NAME:
UH#:

DATE:

Physician Name (print):

Phone
Fax

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