Radiology Requisition

UNIVERSITY OF MICHIGAN HOSPITALS & HEALTH CENTERS Radiology Requisition NAME Routine Results Reporting UMHS REG NO DOB: Urgent Stat Location Code DOS: Sex: Order date: ACC: ICD-9 codes: Bill to Research Account: 700__________________ Clinical Indications (please fill out a separate form for each modality) Ordering Clinician to receive report __ __ __ __ __ __ See label above UMHS Dr. # Attending Physician if different: __ __ __ __ __ __ Interpret Outside Films/Images (list exam type & attach OSH

report if available ) UMHS Dr. # Scheduling Exams - Call Center (734) 936-4500 Patient Safety/Communications Wheelchair http://www.med.umich.edu/rad/preps/radoc.htm Contrast Allergy Any Severe Allergy Asthma Additional Imaging will be performed as indicated by Radiologist. Falls Precautions Interpreter needed (specify): Notify me before additional imaging is performed. 11 - 55 y.o. female (pregnancy testing may be offered or required) Appt. Date: Time: Location: Pregnancy test results: Negative Positive Date: Breast Imaging General Imaging ( walk-in, no appointment necessary ) Screening Mammography Diagnostic Mammography Chest PA/LAT PA only Skull (specify) Procedures Please Indicate location of clinical finding Rib detail (specify): Cervical Spine Core Biopsy Abdomen: Thoracic Spine Fine Needle Aspiration Right Left Pelvis Lumbar Spine Sacrum Wire Localization Hip R L Scoliosis Skeletal Survey Breast Ultrasound MR Breast Other: Upper Extremity Lower Extremity Computed Tomography (CT) Shoulder R L Femur R L Pre-exam Questionnaire: (submit with requisition) Humerus R L Knee R L http://www.med.umich.edu/rad/preps/QuestionnaireCT.pdf Elbow R L Tibia/Fibula R L Cardiac (specify): Forearm R L Ankle R L CT Calcium Scoring - patient is symptomatic or asymptomatic Wrist R L Foot R L Chest Neck(soft tissue) Head (Brain) Hand R L Other: Abdomen Cervical Spine Facial Bone Gastrointestinal(GI)/Urinary Tract(GU) Pelvis Thoracic Spine Orbit...

Website: www.med.umich.edu | Filesize: 111kb
No of Page(s): 2
Download Radiology Requisition.pdf