www.marshallortho.com

GOOD SHEPHERD MC / MARSHALL, TX - OUTPATIENT RADIOLOGY ORDER FORM

FAX WITH FACE SHEET AND COPY OF INS. CARD TO 903-927-6116

PATIENT NAME :   DATE OF BIRTH:  

APPT. DATE / TIME :  AUTH #:

PAYOR:  PROCEDURE:

 

CT SCAN :

IF CONTRAST IS USED, GSMC MARSHALL NEEDS TO PERFORM SERUM CREATININE TEST

PT. WEIGHT:  [LIMIT 400#]   ON GLUCOPHAGE?:

DIABETIC?:  ALLERGY TO IV CONTRAST/IODINE/SEAFOOD/SHRIMP? :

 

MRI :

CARDIAC STENT?  IF YES, BRING STENT CARD             PACEMAKER? :

PREVIOUS BACK SURGERY?:   PT. WEIGHT:  [LIMIT 300#]

 

ULTRASOUND/ECHO:

RADIOLOGY [plain] :  which side ??   

 

NUCLEAR MEDICINE

 

DIAGNOSIS:

_

____         _                       DATE:

Arthur L. Strahan, Jr., MD