17360 HWY 3 DATE: ____________________________

WEBSTER, TX 77598 BUN: ___________________________

PH: 281-338-5575 REFERRAL FORM CREATINE: _______________________
FAX: 281-554-8407 DATE OF LAB WORK: _______________

NAME: _____________________________________________________________DOB: ______________________________

CELL: ___________________________ WORK PH: __________________________ HOME PH: __________________________
1° INSURANCE: ____________________________ PH: ___________________________ ID: ____________________________
2° INSURANCE: ____________________________ PH: ___________________________ ID: ____________________________
DIAGNOSIS: _____________________________________________________ ICD-10: _________________________________
PHYSICIAN: ____________________________________ PH: _________________________ FAX: ________________________
AUTHORIZATION/RQI #: _________________________________ CONTACT PERSON: __________________________________

MRI CT ARTHROGRAM
□ HIGHFIELD □ OPEN □ 3D RECONSTRUCTION − ARTHROGRAM FOLLOWED BY CT
□ ABDOMEN __________________________ □ ABDOMEN □ RT □ LT __________________________
□ BRAIN □ CERVICAL SPINE − ARTHROGRAM FOLLOWED BY MRI
□ IAC □ CHEST / PULMONARY NODULE □ RT □ LT __________________________
□ ORBITS □ HEAD
□ PITUITARY − LOWER EXTREMITY □ RT □ LT US
□ OTHER ____________________________ _____________________________________ □ ABDOMEN COMPLETE
□ CERVICAL SPINE □ LUMBAR SPINE □ ABDOMEN LIMITED ___________________
□ CHEST _____________________________ □ PELVIS − ARTERIAL LOWER □ RT □ LT
− LOWER EXTREMITY □ RT □ LT □ SINUSES − ARTERIAL UPPER □ RT □ LT
_____________________________________ □ SOFT TISSUE ________________________ − CAROTID DOPPLER □ RT □ LT
□ LUMBAR SPINE □ THORACIC SPINE □ RENAL
□ PELVIS − UPPER EXTREMITY □ RT □ LT □ RENAL DOPPLER
□ SACRUM/COCCYX _____________________________________ □ PELVIC
□ SOFT TISSUE ________________________ CONTRAST □ SCROTUM
□ THORACIC SPINE □ WITHOUT □ WITH AND WITHOUT □ SOFT TISSUE ________________________
− UPPER EXTREMITY □ RT □ LT □ THYROID
CTA W/ CONTRAST
_____________________________________ □ TRANSVAGINAL
□ OTHER _____________________________ □ ABDOMEN − VENOUS UPPER EXT □ RT □ LT
CONTRAST □ AORTA − VENOUS LOWER EXT □ RT □ LT
□ WITHOUT □ WITH AND WITHOUT □ AORTA ABDOMINAL □ OTHER _____________________________
□ AORTA THORACIC
MRA □ AORTOILIAC RUNOFF SPECIAL INSTRUCTIONS
□ BRAIN (CIRCLE OF WILLIS) □ CAROTID
□ STAT
□ CAROTID □ CHEST
NOTE: ORDERS RECEIVED AFTER 4PM MAY
□ CHOLANGIOGRAM (MRCP) □ HEAD
BE PROCESSED THE NEXT BUSINESS DAY.
□ MRV □ NECK
□ VERBAL REPORT - INCLUDE CELL:
□ SUBCLAVIAN W/ CONTRAST □ PE STUDY
________________________________
□ PELVIS
□ CLAUSTROPHOBIC
X-RAY □ RENAL STONE
□ SEDATION/VALIUM □ 5mg □ 10mg
□ ___________________________________ CT SCREENING STUDIES □ DOCTOR PROVIDING SEDATION
□ ___________________________________ □ PRE-MEDICATION REGIMEN
□ CORONARY CALCIUM SCORE (SELF-PAY)
□ OTHER _____________________________
□ ___________________________________ □ WHOLE BODY SCAN (SELF-PAY)
□ ___________________________________
This order includes authorization to
□ ___________________________________ perform an orbital x-ray if necessary,
□ ___________________________________ based on patient history and radiologist's PHYSICIAN SIGNATURE:
□ ___________________________________ guidelines and review. _____________________________
NOTE: Weight limit is 350 lbs. for Highfield MRI, 400 lbs. for Open MRI and 500 lbs. for CT.
 17360 HWY 3
WEBSTER, TX 77598
PH: 281-338-5575
FAX: 281-554-8407

INSTRUCTIONS

BUN & Creatine results required for CT & MRI Contrast studies, if:

▪ Patient > 50 years of age

▪ Hx of Hypertension
▪ Hx of Diabetes
▪ Hx of Kidney Disease

MRI Patients must not have:

▪ Pacemakers
▪ Aneurysm Clips
▪ Inner Ear Implants
▪ Dorsal Column Stimulators
▪ Pain Pump

LOCATION & MAP

We are conveniently located near Medical Center Boulevard on Highway 3.

NOTE: Weight limit is 350 lbs. for Highfield MRI, 400 lbs. for Open MRI and 500 lbs. for CT.