RP Long Bay
If your doctor has ordered contrast, you may be receiving oral and/or IV contrast. Take all medications with a clear liquid on the day of your test. X-ray 2 2 Ultrasound Broadway at the Beach Hwy. Dept. 900 21st Ave. North Myrtle Beach Convention Center Oak Street Farlow Street Hwy 17 Bypass Abdomen, RUQ, Renal and Aorta: Nothing to eat or drink after midnight or 6 hours prior to exam. Pelvic/Bladder, Renal (Kidneys and Bladder): Full bladder required. All must drink 32 oz. of water 1 hour prior to exam. 900 21st Ave. N. | Myrtle Beach, SC 29577 Ph: 843-916-1700 Fax: 843-916-9460 Tax ID# 571013875 Fax Scheduling 843-916-9460 Call patient to schedule www.scdiag.com Patient Name:_________________________________________________________________ DOB:______________________________ Appointment Date:________/_________/____________ Arrival Time:__________am / pm Appointment Time:___________am / pm Phone Number: Primary:_____________________________________ MRI Contrast: Rad Discretion with without with & w/o Brain Brain IACs Brain Pituitary Orbits Soft Tissue Neck TMJ Cervical Spine Thoracic Spine Lumbar Spine Sacrum Shoulder Rt Lt Elbow Rt Lt Wrist Rt Lt Hand Rt Lt Pelvis Rt Lt Hip Rt Lt Knee Rt Lt Ankle Rt Lt Foot Rt Lt Abdomen MRCP MRA Head MRA Carotid MRA Abdomen MRA Renal MRA Aorta Other:__________________ CT Contrast: Rad Discretion with without Head Orbits Temporal Bones/IACs Facial Bones Paranasal Sinus Paranasal Sinus Stereotactic Protocol:______________ Soft Tissue Neck Chest Hi Res Chest Abdomen Attn: Kidney Mass Attn: Pancreas Attn: Liver Attn: Stone Search Pelvis Dental Implants (type) CT Angiography (CTA) Chest/PE Protocol Head Carotids Abdomen/Aorta Abdomen/Pelvis-Renal Abdomen w/ Bilateral Lower Extremity Runoff Spine w/3D Recon □ Yes □ No Cervical Thoracic Lumbar Extremity w/3D Recon □ Yes □ No Ankle Elbow Foot Knee Wrist Shoulder Hip Other (specify) _____________________________ Secondary:_______________________________________ Ultrasound General Abdomen Complete (organs above umbilicus) Right Upper Quadrant (Liver, Gallblader, Rt Kidney, Pancreas) Left Upper Quadrant (Spleen, Lt Kidney) Pelvis (Transvaginal as indicated) Renal (Kidneys & Bladder) Aorta Thyroid Scrotum with Doppler Groin Other:_______________ Vascular Carotid Doppler Lower Venous Doppler Upper Venous Doppler X-ray Chest KUB Abd-Supine & Upright Abd Series (incl. PA CXR) Cervical Thoracic Lumbar Pelvis Ribs Rt Lt Hip Rt Lt Shoulder Rt Lt Wrist Rt Lt Hand Rt Lt Knee Rt Lt Ankle Rt Lt Foot Other______________ *Walk In X-ray from 9am - 3pm Image Delivery CD Report Delivery Rt Lt Bilat Rt Lt Bilat Within 24 hours STAT Fax Fax#_______________ Call Report Cell or Backline #: ___________________ Comparisons Comparison Studies Location:________________ Clinical Indications/Signs/Symptoms: ______________________________________________________________________________ Special Instructions: ____________________________________________________________________________________________ Physician Name (Printed)________________________________________ Physician Signature_________________________________ RP-SC-LONG_Rev. 02/2015
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