Imaging Referral Request
Imaging location
*
Elk Grove Diagnostic Imaging
Patient Information
Patient Name:
*
First Name
Last Name
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Is the patient pregnant?
*
Yes
No
Patient DOB
*
-
Month
-
Day
Year
Date
Patient Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Patient Email
Home Address:
Address
Street Address Line 2
City
State
Zip Code
Patient Demographics:
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Referral Information
Was this due to an injury?
*
Yes
No
Date of Injury
*
-
Month
-
Day
Year
Date
Patient's Attorney:
*
Name
Attorney Phone:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Attorney Email:
*
example@example.com
Reason for referral: Please choose a modality
*
Open MRI
Open MRA
Ultrasound
X-ray
With or Without Contrast
With Contrast
Without Contrast
Open MRI
MRI Brain
MRI Cervical Spine
MRI Thoracic Spine
MRI Lumbar Spine
MRI Chest
MRI Shoulder - Specify Right and/or Left
MRI Elbow -Specify Right and/or Left
MRI Wrist - Specify Right and/or Left
MRI Hip - Specify Right and/or Left
MRI Knee - Specify Right and/or Left
MRI Ankle - Specify Right and/or Left
MRI Pelvis - Specify Right and/or Left
Other
MRI PI Study Only
Flexion/Extension - MRI C-Spine & L-Spine
Weight-Bearing MRI L-Spine Only
Open MRA
MRA Brain
MRA Neck
MRA Other
Ultrasound
Ultrasound Abdomen
Ultrasound Thyroid
Ultrasound Carotid (vascular)
Ultrasound Pelvis
Ultrasound Testicular
Ultrasound Renal
Ultrasound Bladder
Ultrasound Aorta
Ultrasound Extremity - Specify body party
Ultrasound Obstetrics - Specify body party
X-Ray - Please indicate body parts & views in Indication
X-Ray Sinus Series
X-Ray Chest - Indicate views
X-Ray Abdomen
X-Ray Hip - Indicate Right and/or Left
X-Ray C-Spine - Indicate views
X-Ray T-Spine - Indicate views
X-Ray L-Spine - Indicate views
X-Ray Upper Extremity - Specify body part & Indicate Right and or Left
X-Ray Lower Extremity - Specify body part & Indicate Right and or Left
Indication/Diagnosis Code:
List procedure requested
Is this referral medically urgent?
*
Yes
No
Describe the urgency:
History/Chart Notes/Exam Details:
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Patient Insurance/Other:
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Referrer Information
Referring Provider:
*
First Name
Last Name
Company Name:
Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Fax Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Provider Email
*
Office Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Notes of Referrer:
Upload Signature:
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Provider Signature:
*
Date:
-
Month
-
Day
Year
Date
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Submit
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