CT/MRI/Sono/NM/Xray Appointments: (718)270-4438

Mammography Appointments: (718)270-7333

Fax: (718)270-4172
History:

UHB Radiology Request Form Physician’s Signature

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PATIENT NAME: Patient MR# ICD Code:
DOB: Patient’s Contact #:
Precert/Auth#s: Patient’s Address:
Referring Doctor: Doctor’s Contact #:
Doctor’s NPI: Date Issued: Serial #
XRAYS MRI CT PET/CT WOMEN’S
Chest Creat./GFR TEST Creat./GFR TEST I.V. CONTRAST IMAGING &
PA PA/LAT Other W/out GAD I.V. CONTRAST WITH
Abdomen W & W/o GAD contrast With Without Skull Base to Thighs BREAST IMAGING
Flat Erect Decub Brain BUN/CREAT Brain Mammography
Pelvic A/P Standing Routine Brain Brain Metabolism Screening: Routine;
Ribs R L Seizure Sinuses Facial Bones Myocardial Viability Asymptomatic
Head Brachial Plexus Orbits Diagnostic Bilateral: Lump,
Skull Sinus Orbits Pituitary Temporal Bones Pain, Personal hx of breast
NUCLEAR ca
Facial Bones Orbits Neck
Nasal Bones Mandible IAC’s Chest MEDICINE Diagnostic Unilateral
131 123
Cervical Spine Neck CT Guided Lung Biopsy I Uptake and Scan I R L
131
2 Views 4 Views Chest Abdomen I Uptake and Scan TCO4 Mammography &
131
Standing Flex/Ext C-Spine Liver I Radioactive Treatment Ultrasound (If indicated)
Thoracic T-Spine Pancreas Protocol Lung V/Q Scan Screening Dx
Standing L-Spine Pelvis Sentinel Node Injection Ultrasound (Indicate
Lumbar Spine Total Spine - Scoliosis Abd/Pelvis Brain Spect Problem on diagram)
2 Views 4 Views Total Spine – Metastatic CT Virtual Colonosography Whole Body Bone Scan Breast MRI (Give Indication
Standing Flex/Ext Survey Hematuria/Urogram 3 Phase Bone Scan below)
Scoliosis Series Breast (bilateral) w/CAD Renal Stone (No Contrast) I 131 Whole Body Breast Biopsies
Bending AP Abdomen SPINE Limited Bone Scan Ultrasound Core Biopsy
AC Joints Liver C-Sp T-Sp L-Sp Site:__________________ R L
Clavicle R L Pancreas Musculoskeletal R L Liver/Spleen Scan MRI Core Biopsy
Scapula R L MRCP MIBG R L
CT Gallium Scan Fine Needle Aspiration
Shoulder R L Kidney & Adrenal urogram
Humerus R L MR ANGIOGRAPHY Octreo Scan R L
Elbow R L Pelvis Creat/GFR TEST Indium 111 Stereotactic Core Biopsy
Forearm R L Shoulder R L BUN/CREAT Renal Flow & Scan R L
Wrist R L Elbow R L CT Angio Chest (PE Renal Flow & Scan w/Lasix Post Biopsy clip Placement
Hand R L Wrist R L Protocol) Renal Flow & Scan R L
Finger______________ Hand R L Brain w/Captopril Wire Localization
Hip R L Hip R L Lower Ex Ext. Veng Renal – DMSA R L
Femur R L Knee R L Neck/Carotid HIDA
Knee 2 R L Ankle R L Perfusion HIDA with Ejection Fraction
123
Knee 3 R L Foot R L Coronary Arteries/Heart Thyroid I Uptake & Scan
Knee 4 R L Lower Extremity R L Chest Parathroyd Sestambli Scan
TibFib R L Long Bone R L Dissection SPECT
Ankle R L Hip Artho R L Abdominal Aorta Gastric Emptying
Foot R L Shoulder Arthro R L Runoff Study Hepatic Hemangioma ULTRASOUND
Toe________________ Other ___________ L.E. CTA Thyroid
Weightbearing Y N MR BONE Abdomen
Other Note: Exams may be Abdomen Limited
ANGIOGRAPHY performed with 3d post DENSITOMETRY
DEXA Aorta
I.V. CONTRAST processing on an
FLUOROSCOPY WITH WITHOUT independent work station
Renal
Hysterosalpingogram Bladder
WITH & WITHOUT where clinically Indicated ULTRASOUND Hysterosonagram
Esophagram Intercranial (Brain) Note: Examinations will be
Modified Swallow BIOPSIES Pelvic-Transabdominal
Extracranial (Neck) performed with IV contrast Only
Upper GI Thyroid FNAB R L
Thorasic Aorta where clinically indicated Transvaginal Only
Small Bowel Series Lymph Nodes FNAB R L
Renal Artery Pelvic Combined-
Barium Enema Air Parotid FNAB R L
Abdomen (Abdominal (Transabdominal/
Therapeutic Inj. R L Aorta/Renal/Celiac Axis) Transvaginal)
VCU Pelvis OUTSIDE FILM
Body Part Testicular/Scrotal
MRV Body REVIEW Musculoskeletal
MRV Brain Prior Images On CD R L
Requesting Study on CD Diagnostic Body Part
___________________