Fax Scheduling 843.747.6565 TRICOUNTY RADIOLOGY ASSOCIATES Call patient to schedule Moncks Corner │ North Charleston │West Ashley Tax ID #: 56-2231622 Ph: 843.529.0600 www.scdiag.com (See reverse side for address & directions) Patient Name:_________________________________________________________________ DOB:______________________________ Appointment Date:________/_________/____________ Arrival Time:__________am / pm Appointment Time:___________am / pm Phone Number: Mobile:_____________________________________ MRI Contrast: Rad Discretion with without with & w/o Brain IAC w/wo Pituitary Orbits w/wo Seizure Protocol Cervical Spine Thoracic Spine Lumbar Spine Soft Tissue Neck MRA of:___________ Stroke Protocol (Brain, MRA Head, MRA Neck) Abdomen Rt Lt Bilat Shoulder Rt Lt Bilat Elbow Rt Lt Bilat Wrist Rt Lt Bilat Hip Rt Lt Bilat Knee Rt Lt Bilat Ankle Rt Lt Bilat Foot Forefoot Hindfoot MR Arthrogram Rt Lt ________________________ Other___________________ ________________________ CT Other:_______________________________________ Ultrasound Contrast: Rad Discretion with without with & w/o Abdomen Gallbladder (Right Upper Quadrant) Renal (Kidneys & Bladder) Brain Pelvic (Transvaginal as indicated) Orbits Carotid Doppler Paranasal Sinus Venous Doppler Paranasal Sinus Stereotactic RUE LUE RLE LLE Stealth/Brain Lab Duplex Aorta, IVC, Iliac Vas, or Fusion Bypass Grafts Temporal Bones/IAC Limited Facial Bones Complete Abdomen & Pelvis Follow-up Stone Protocol OB Abdomen (only) Thyroid Scrotum - with Doppler Pelvis (only) Chest Soft Tissue Neck C-Spine L-Spine T-Spine CTA (all w & w/o) Abdomen Pelvis Head Aorta Neck (Run-off) Dedicated Studies (all w & w/o) Adrenal Pancreas Liver Renal Advanced Imaging 3D Reconstruction ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ Comments ______________________ ______________________ Other:_____________________ ______________________ __________________________ ______________________ __________________________ __________________________ Fluoroscopy IVP IVP with Tomography Barium Swallow Upper GI (includes limited esophagram) Small Bowel Follow Through Other:_________________ Cardiac Score X-ray Please specify: Bone Densitometry Bone Mineral Densitometry (DEXA) ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ Report Delivery Within 24 hours STAT Fax Fax#_______________ Call Report Cell or Backline #: ___________________ Clinical Indications/Signs/Symptoms: ______________________________________________________________________________ Physician Name (Printed)________________________________________ Physician Signature_________________________________ RP-SC-TRI_Rev. 01/2015 TRICOUNTY RADIOLOGY ASSOCIATES Moncks Corner │ North Charleston │West Ashley Visit our website www.scdiag.com to see pictures of our equipment and view maps. MRI (Magnetic Resonance Imaging) Please have patient contact our office 24 hours before appointment for prep instructions. Do not wear any eye make-up for ALL Head & Neck studies. CT (Computed Tomography) Please have patient contact our office 24 hours before appointment for prep instructions. Fluoroscopy by mouth after midnight ..Nothing UGI (Barium Swallow) . Esophogram Small Bowel Follow Through . Pick up prep kit from one of our offices IVP (Nothing by mouth 2 hours prior to exam) Ultrasound .. . Bladder ..FullPelvic OB or Non OB: 32-40 oz of water (4-5 [8oz] glasses) . 1 hour before exam Nothing by mouth after midnight Abdominal Gallbladder Renal (also see Full Bladder prep) .. .. No special prep Thyroid Scrotum Carotid Venous 52 Berkely Baptist Church 52 . S8- 5 0 i c al P l a za D ri Health South Hospital Tricom St. Edenbrook Trident Hospital ve ed M Silk Oak Dr. Berkely Co. Water & Sanitation S .R Dunkin Donuts I-26 E Berkeley Family Practice Charleston Southern University Towards Towards S’ville Hwy 78 Rivers Ave. Home Depot Magwood Drive I-26W Our Locations Hw y. 6 526 1 (Next to Kohl’s) Chick-Fil-A Paul Cantrell Blvd. St. Francis Hospital Moncks Corner 2061 Hwy 52 S, Suite 400 Moncks Corner, SC 29461 (located inside Berkeley Family Practice) North Charleston 2851 Tricom St. N. Charleston, SC 29406 West Ashley 1975-H Magwood Rd. Charleston, SC 29414 Hw y. 6 1 Mark Clark 7 Hwy. nberg itte Sam R
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