Imaging Referral Request
Imaging location
*
Hilltop Imaging & Diagnostic Center
Patient Information
Patient Name:
*
First Name
Last Name
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Patient DOB
*
-
Month
-
Day
Year
Date
Patient Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Is the patient pregnant?
*
Yes
No
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
Sports Injury
Work Injury
Other
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
CT
Ultrasound
X-ray
With or Without Contrast
With Contrast
Without Contrast
Open MRI
MRI Brain
MRI Orbits
MRI Neck (soft tissue)
MRI Cervical Spine
MRI Thoracic Spine
MRI Lumbar Spine
MRI Abdomen
MRI Pelvis
MRI Shoulder - Right
MRI Shoulder - Left
MRI Elbow -Right
MRI Elbow -Left
MRI Wrist - Right
MRI Wrist - Left
MRI Hand - Right
MRI Hand - Left
MRI Hip - Right
MRI Hip - Left
MRI Knee - Right
MRI Knee - Left
MRI Ankle - Right
MRI Ankle - Left
MRI Foot - Right
MRI Foot - Left
Specify Other
MRI PI Study Only
Flexion/Extension - MRI C-Spine & L-Spine
Weight-Bearing MRI L-Spine Only
Open MRA
MRA Brain
MRA Neck
CT
CT Cervical Spine
CT Thoracic Spine
CT Lumbar Spine
CT Brain
CT Sinuses
CT Chest
CT Shoulder - Specify Right and/or Left
CT Elbow - Specify Right and/or Left
CT Hip -Specify Right and/or Left
CT Knee - Specify Right and/or Left
CT Ankle - Specify Right and/or 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-rays are walk-in only)
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.
Email
*
Office Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Notes of Referrer:
Provider Signature:
*
Date:
-
Month
-
Day
Year
Date
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