Form H Mr 1097 – Fill Out and Use This PDF

DOB: _________ Pt weight < 300 lbs YES NO Patient Contact Phone #_________________

Procedure/Study to be done with specific location / side of lesion:____________________________________

__________________________________________________________________________________________

Diagnosis/Indication: ____________________________________ ICD-9 Code__________________

1. Can patient consent for procedure? YES			NO Next of Kin/Contact# _______________________
2.	Medication or Contrast Allergy:	YES	NO __________________________________________
3. Contact Precautions? YES		NO ________________________________________________
4.	Currently taking Anti-coagulant Medications? YES NO _____________________________
5. Does patient have all of the following lab test results (within 30 days): YES NO
BUN _______ Creatinine ______		Platelets _______ PT ________ PTT _______ INR ________

(Blood work is only needed for biopsies requiring sedation and/or pt taking anticoagulant medications)

6.Does patient require any special accommodations? YES NO ___________________________

•Radiology reserves the right to cancel and/or reschedule patient if:

(1)lab results are not posted within 24 hours of scheduled exam date

(2)if patient is 1 hour late for scheduled arrival time; or

(3)lack of transport home.

•Referring physician’s instructions to patient should include NPO status, on-time arrival, and a responsible individual for transport home.

______________________________________________________________________ _____________		_____________
Requesting Physician: Printed Name and Signature / Pager	Date	Time
Office/Clinic Contact Person: ____________________________	Phone #: ______________________
Office/Clinic VM Location: _______________________

When you have completed this form: Fax Completed Request Form, H&P/Clinic Notes, Current Medication List and Lab Results (within 30 days) to:

828-7926 (Interventional Radiology – Vascular and Neuro)

828-5570 (Ultrasound and CT -Chest/Lung)

827-1869 (MSK, CT – abdomen, myelograms, lumbar punctures)

Contact Phone Numbers: 828-6986/pager 2599-triage (Interventional Radiology) 828-3180/pager 4550 or 4474 (Ultrasound and CT – Chest/Lung) 828-5045/pager 7877 (Musculoskeletal procedures)

628-4612/pager 2546 (Myelograms/ lumbar punctures)

828-4467/pager 2548 (Virtual colonoscopy/abdomen)

H-MR-1097 (12-08) (rev. 03-09)	Medical Record Copy
Radiology