IMAGING REQUISITION
Patient Information
Name
*
First Name
Last Name
Height
Weight
DOB
*
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient's Telephone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Sex
*
Male
Female
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Primary Insurance Information
Insurance Name
*
Policy #
*
Group #
Is the patient the Insurance Subscriber?
Yes
No
Insurance Subscriber's Name
Insurance Subscriber DOB
-
Month
-
Day
Year
Date
Relationship to patient:
Please Select
Husband
Wife
Son
Daughter
Other
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Secondary Insurance Information
Does patient have a secondary insurance?
*
Yes
No
Insurance Name
Policy #
Group #
Is the patient the Insurance Subscriber?
Yes
No
Insurance Subscriber's Name
Insurance Subscriber's DOB
-
Month
-
Day
Year
Date
Relationship to patient
Please Select
Husband
Wife
Son
Daughter
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Appointment Request
(Will be reviewed by In the Image staff to confirm date/time availability. )
Appointment
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Exam Request
ICD Code
*
Pre-Auth Required
No
Yes
Pre-Auth #
Cardiology Exam
Echocardiography, Transthoracic; includes M-mode recording
Echocardiography, Transthoracic; Limited/Follow-Up Exam
Echocardiography, Transthoracic; with contrast; includes M-mode
Echocardiography, Transthoracic; Limited; with contrast
Cerebrovascular Arteries/Carotid Doppler
Ankle/Brachial Index Bilateral
Ankle/Brachial Index Unilateral
Electrocardiogram/EKG
Other
Vascular Exam
Venous Leg (RT)
Venous Leg (LT)
Venous Leg BILATERAL
Venous Arm (RT)
Venous Arm (LT)
Venous Arm BILATERAL
Arterial Leg (RT)
Arterial Leg (LT)
Arterial Leg BILATERAL
Arterial Arm (RT)
Arterial Arm (LT)
Arterial Arm BILATERAL
Extremity Nonvascular
Renal Doppler/Duplex
Renal Doppler/Duplex Add Renal Ultrasound
Mesenteric Artery
Aorta Duplex
Other
Notes/Comments
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Referring Physician Information
Physician Name
*
NPI #
*
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Fax Number
Please enter a valid fax number.
Format: (000) 000-0000.
Email (Exam results will be sent here.)
example@example.com
Submit
Should be Empty: