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SCHEDULING APPOINTMENT FOR:
Mammo, Ultrasound, X-ray Call: (541) 382-9383 This facsimile transmission contains confidential information to the sender which is protected by the physician -patient privilege. If you are not the intended recipient, you are hereby notified that any disclosure, copying, After Appointment Is Scheduled Please Fax This Order To: 382-6635
distribution or taking action of any kind in reliance to the information contained is strictly prohibited. If you receivedthis transmission in error, please notify the sender by phone immediately to arrange for return of documents.
Clinical Hx / Note to Radiologist / Tech: Physician’s Signature (required) X
X-RAY (cont.)
X-RAY (cont.)
PLEASE MARK EXAM(S) & EXAM TYPES
PLEASE MARK EXAM(S) & EXAM TYPES
PLEASE MARK EXAM(S) & EXAM TYPES
UPPER EXTREMITIES (cont.)
MISCELLANEOUS
❑ Bone Age (PA - Bilateral Hands / Wrists) ❑ Wrist 3+ V (PA / Lateral & Oblique) ❑ Scanogram (AP / Hips - Knees - Ankles) ❑ Other: ________________________________ BREAST IMAGING
❑ Fingers (PA Hand / Lateral & Oblique) LOWER EXTREMITIES
❑ Chest (Apical Lordotic & PA / Lateral) ❑ Bilateral Hip 2V (Including AP Pelvis) ❑ Breast Ultrasound To Compliment Mammo (unilat.) ❑ Breast Ultrasound To Compliment Mammo (bilat.) ❑ Breast Ultrasound (Unilat or Bilat W/O Mammogram) ❑ Additional Views To Complete Mammogram HEAD & NECK
❑ Knee 3+ V (AP / Lateral & Oblique) ULTRASOUND
❑ Ankle 3+ V (AP / Lateral & Oblique) ❑ Facial Complete (PA / Waters / Lateral) ❑ Foot 3+ V (AP / Lateral & Oblique) ❑ Toes (AP Foot / Lateral & Oblique) SPINE & PELVIS
❑ Cervical Complete (AP / Lateral / OM / Obliques) ❑ Pelvic ❑ Thoracic / Swimmers (AP / Lateral / Swimmers) ❑ Thoracic / Lumbar Junction (AP / Lateral) UPPER EXTREMITIES
❑ Lumbar Minimum 4V (Bi Plane Bending Only) ❑ Obstetrical (Twins 2nd - 3rd Trimester) ❑ Lumbar Complete (AP / Lateral / Obliques / L5-S1 Spots) ❑ Fetal Positioning Only ❑ AC Joint (With & Without Weights) ❑ Other: ________________________________ ❑ Elbow 3+ V (AP / Lateral & Oblique) PLEASE MARK EXAM(S) & EXAM TYPE(S)
PLEASE MARK EXAM(S) & EXAM TYPE(S)
BRAIN OR HEAD
CERVICAL SPINE
ABDOMEN - PELVIC AREAS
COMPLETE P. FOSSA TEMP. BONE ORBIT LEVELS OF INTEREST: ___________________
UPPER ABDOMEN (Diaphragm to Iliac Crest)
ABDOMEN & PELVIC
ABDOMEN ONLY
MAXILLOFACIAL
THORACIC SPINE
LEVELS OF INTEREST: ___________________
PELVIC (Iliac Crest through Symphisis)
NASAL SINUSES
PELVIC & ABDOMEN PELVIC ONLY
LUMBAR SPINE
LEVELS OF INTEREST: ___________________
SOFT TISSUE NECK
UPPER EXTREMITY
CHEST - THORAX
CT. ANGIOGRAPHY
LOWER EXTREMITY
Ply 1 - Fax to (541) 382-6635, Keep Original Ply 2 - Patient Copy
SCHEDULING APPOINTMENT FOR:
Mammo, Ultrasound, X-ray Call: (541) 382-9383 (In the Westside Medical Center - Upper Level)
PATIENT -
If your doctor’s office has given you x-rays, please bring them with you to your appointment! See location map on backIf you have any questions about your exam or prep, please call our scheduling department at the above phone number REFERRING OFFICE -
Please check the appropriate exam prep for your patient.MAMMOGRAM
1. Bathe or otherwise carefully cleanse your breasts and underarms before your exam. Be careful to remove all deodorant, perfume, powders or preparation of any sort in the 2. You will find it more convenient to wear a blouse with slacks or a skirt, rather than a dress.
3. If you have had a mammogram at another facility please bring it with you or request that it be sent to us.
4. Allow approximately 45 minutes for your exam.
ROUTINE X-RAY(s)
There is no preparation for this exam. Allow approximately 45 minutes for your exam.
ULTRASOUND
PELVIS or OB
RENAL / KIDNEY
Your bladder must be full to obtain a thorough exam. Drink 16 ounces of water Your bladder must be full to obtain a thorough exam. Drink 16 ounces of water approximately 1 hour before your appointment time and DO NOT empty your bladder.
approximately 1 hour before your appointment time and DO NOT empty your Allow approximately 1 hour for your exam.
bladder. Allow approximately 1 hour for your exam.
UPPER ABDOMEN and GALLBLADDER
ARTERIAL LEGS
Nothing to eat or drink for at least 10 hours before your exam. Allow approximately 1 hour Do not eat or drink anything for 4 hours prior to your exam. Allow approximately 90 ❑ ALL OTHER ULTRASOUND EXAMS
There is no preparation. Allow approximately 1 hour for your exam.
CT SCANS - IMPORTANT INFORMATION
After you enter the scan room the radiographer will position you on a special table. The area to be scanned will be moved into the ring, whichcontains an x-ray tube and computer receptors. The radiographer will control the scanner and monitor the progress of the exam from anadjacent room where s/he is able to see and hear you.
Frequently it is necessary to use an IV medication called contrast to highlight certain structures. This medicine will be given through a vein inyour arm. During the injection you may feel warm and flushed and have a metallic taste in your mouth. These are normal side effects, whichonly last for a few minutes. True allergic reactions are rare but can occur with this material.
It is important to remember that every patient and exam is different. Consequently some scans will take longer or be more involved than others.
A radiologist will interpret your scan and send a report to your physician within 48 hours. Please contact our office and ask to speak with a CTradiographer if you have any questions regarding your scan or prep instructions. For pediatric patients - call our office for special instructions.
CT SCAN of the SINUS, EXTREMITY or CT IVP
CT SPINE
There is no preparation for these exams.
There is no preparation for a routine spine CT.
Allow approximately 40 minutes for your exam.
Allow approximately 1 hour for a routine spine scan.
CT SCAN of the HEAD, CHEST or NECK
If you are scheduled for a myelogram with a CT to follow - ask your Nothing to eat or drink for 4 hours prior to your exam.
physician for a special instruction sheet. You may also pick this sheet You may take your normal medicines with the exception of Glucophage (metformin) or Glucovance.
CT SCAN of the ABDOMEN and/or PELVIS
If you take Glucophage or Glucovance or are allergic to radiologic Pick up 3 oral Hypaque doses at Cascade Medical Imaging.
contrast media, call our office at least the day before your exam for Mix any one of the syringes of Hypaque with 12 ounces of clear juice (any type without pulp such as cranberry or apple) and drink at 8:OO
Allow approximately 1 hour for your scan.
pm THE EVENING BEFORE your appointment.
CT ANGIO
Mix another syringe of Hypaque with 12 ounces of juice and drink 2
Nothing to eat or drink for 4 hours prior to your exam.
HOURS PRIOR to your exam time.
You may take your normal medicines with the exception of Mix the last syringe of Hypaque with 12 ounces of juice and drink 1
Glucophage (metformin) or Glucovance.
HOUR PRIOR to your exam time.
If you take Glucophage or Glucovance or are allergic to radiologic Do not eat or drink anything else for 4 hours prior to your exam with contrast media, call our office at least the day before your exam for the exception of medications already prescribed by your physician.
If you are diabetic continue your usual diet along with the Hypaque at For a CT angio of your abdominal aorta - drink 1 gallon of water two the appropriate times. DIABETIC PATIENTS TAKING GLUCOPHAGE (metformin) or GLUCOVANCE - contact our office Allow approximately 1 hour for your scan.
for special instructions about taking your medication.
If you have previously had a reaction to x-ray contrast call our office CT COLONOSCOPY
Pick-up an Evac-Q-Kwik kit from our office.
Inform the radiographer if you have asthma, diabetes, heart or renal Follow the TWO DAY prep instructions found inside the box.
problems or could possibly be pregnant.
Allow approximately 1 hour for your scan.
You may experience some diarrhea with this oral prep.
10. Allow approximately 1 hour for your scan.
Galveston
Skyliner
Colorado Ave.
Simpson Ave.
Cascade Medical
Imaging, LLC
olorado Ave.
Reed Market
ton D Yates
1693 SW Chandler (In the Westside Medical Center - Upper Level)

Source: http://www.cascademedicalimaging.com/webdocuments/cmi-bend-order-form-patient-prep.pdf

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