Referral Form

Please Complete the Following Form and a Member of
Our Staff Will Promptly Contact You.

Patient Name:

Date and Time of Appointment:

Reason for Test:

ICD9 Code :

Referring Doctor:

Stat Report Phone Number:

Fax Number:

BREAST IMAGING:
Screening Mammogram
Diagnostic Mammogram
Breast Ultrasound
Other

BONE DENSITOMETRY:
Standard Spine/Femur
Forearm

PET/CT
Oncology, cancer type

Cardiac Scoring
CT Lung Screening

ULTRASOUND WITH COLOR DOPPLER
Abdominal
Liver, GB, pancreas, kidney, aorta
Pelvic
(including transvaginal, transabdominal)
Extremity
Thyroid
Venous Dopplex
unilateral bilateral
Carotid
OB
Soft Tissue
Other

X-RAY
R/L Hand R/L Finger Thumb R/L Wrist R/L Foot R/L Toe R/L Ankle R/L Shoulder R/L Rib Detail R/L Hip R/L Knee R/L Femur	Chest 1/2/3/ views Sinus Series Lumbar Spine Thoracic Cervical AP Pelvis Coccyx Other

PATIENT INSTRUCTIONS: Please check appropriate instructions for patient.
If you have previous study/films/reports, please bring with you to your appointment.
Mammogram: No deodorant, powder or lotion under arms.
Pelvic or OB Ultrasound: Drink 32 oz (4 cups) of liquid about 2 hours before test. Do not urinate.
Abdominal/ Kidney/ Liver/ Gallbladder Ultrasounds: do not eat or drink for 6 hours prior to exam.
PET/CT: Please contact Angel Williamson Imaging Center at least 48 hours prior to test for instructions.
Other instructions: