Imaging Referral Request
Imaging location
*
Roseville Diagnostic Imaging
Patient Information
Patient Name:
*
First Name
Last Name
Is the patient pregnant?
*
Yes
No
Patient DOB
*
-
Month
-
Day
Year
Date
Patient Phone Number:
*
Please enter a valid phone number.
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
What type of Injury?
*
Motor Vehicle Accident
Work Injury
Sports Injury
Other
Date of Injury
*
-
Month
-
Day
Year
Date
Patient's Attorney:
*
Name
Attorney Phone:
*
Please enter a valid phone number.
Attorney Email:
example@example.com
Reason for referral: Please choose a modality
*
MRI
MRA
CT
Ultrasound
X-ray
With or Without Contrast
*
Without Contrast
With Contrast* - Contrast patients require BUN & Creatinine labs within 6 weeks.
Is the patient Claustrophobic?
*
Yes - Patient needs an Open MRI
No
MRI
MRI Brain
MRI Cervical Spine
MRI Thoracic Spine
MRI Lumbar Spine
MRI Chest
MRI Shoulder - Right
MRI Shoulder - Left
MRI Elbow -Right
MRI Elbow - Left
MRI Wrist - Right
MRI Wrist - Left
MRI Hip - Right
MRI Hip - Left
MRI Knee - Right
MRI Knee - Left
MRI Ankle - Right
MRI Ankle - Left
MRI Pelvis - Right
MRI Pelvis - Left
Other
MRI PI Study Only
Flexion/Extension - MRI C-Spine & L-Spine
Weight-Bearing MRI L-Spine Only
MRA
MRA Brain
MRA Neck
MRA Other
CT
CT Cervical Spine
CT Thoracic Spine
CT Lumbar Spine
CT Brain
CT Sinuses
CT Chest
CT Shoulder - Right
CT Shoulder - Left
CT Elbow - Right
CT Elbow - Left
CT Hip - Right
CT Hip - Left
CT Knee - Right
CT Knee - Left
CT Ankle - Right
CT Ankle - Left
CT Pelvis
CT Abdomen
CT 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 - 1-2 views
X-Ray Chest - 3-4 views
X-Ray Abdomen
X-Ray Hip - Right
X-Ray Hip - Left
X-Ray AP Pelvis - include iliac crest & Ischial tubs
X-Ray C-Spine - 1-2 Views
X-Ray C-Spine - 3-4 views
X-Ray C-Spine - 3 Views APOM, AP LAT
X-Ray C-Spine - 5+ views
X-Ray T-Spine - 1 View AP
X-Ray T-Spine - 1-2 views
X-Ray T-Spine - 3-4 views
X-Ray L-Spine - 2 Views AP, LAT
X-Ray L-Spine - 1-2 views
X-Ray L-Spine - 3-4 views
X-Ray L-Spine - 5+ views
X-Ray Upper Extremity Right- Specify body part
X-Ray Upper Extremity Left - Specify body part
X-Ray Lower Extremity Right - Specify body part
X-Ray Lower Extremity Left - Specify body part
X-Ray Other - Specify
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.
Fax Number:
*
Please enter a valid phone number.
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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