1. No category

Professional radiology services provided by:
Tennessee Interventional and Imaging Associates
Patient Name:
Exam Requested (if not listed below):
ERLANGER INTERVENTIONAL RADIOLOGY REQUEST FORM
Date of Birth:
Phone #:
Appt. Date: Time:
Diagnosis / ICD-9 Code:
Special Instructions:
Physician Signature:
_____________________________________________________________________________
Printed Physician Name:
___________________________________________________Contact #: _________________
Report:
Call
Fax To: _______________________________________at: __________________________Ph/Fax #
NEURO:
GI/BILIARY:
Cerebral Angiogram
Cerebral Venogram
Cerebral Aneurysm Coil Embolization
Cerebral / Spine
AVF
AVM Embolization
Carotid Angiogram with
without Stent Placement
Head/Neck Mass Preoperative Embolization: (Specify Type)
Meningioma
Carotid Body Tumor
Other: ____________
Kyphoplasty Specify level: ____________________________________
Lumbar Puncture:

w/ opening pressure

w/ intrathecal chemotherapy (Rx_____________)

w/ intrathecal contrast (check CT myelogram also)

w/ lumbar drain placement
Epidural blood patch placement -Specify Level: ____________________
Epidural steroid injection -Specify Level: ________ w/ Transforaminal
Facet steroid injection -Specify Level: ____________________________
IR CONSULTATION: Reason: __________________________________
Other: ____________________________________________________
VASCULAR:
Angiography
Aortic:
Thoracic
Abdominal
Pulmonary
Renal
Pelvic
Upper Extremity:
Right
Left
Lower Extremity:
Right
Left
Mesenteric: (incl. Celiac, SMA, IMA)
Venography:
Upper extremity:
Right
Left
Lower extremity:
Right
Left
Superior Venocavagram
Inferior Venocavagram
Arterial intervention:
Angioplasty
Stent
Venous Intervention (angioplasty, stent, foreign body retrieval)
Body Aneurysm coil embolization: -Specify site: ___________________
Body
AVM
AVF Embolization: -Specify site: ______________
IVC Filter: :
Placement
Removal
Endovenous laser ablation
PICC: Initial Placement
Exchange Reposition
IR CONSULTATION: Reason: __________________________________
(i.e. aneurysm, stenosis, AVM)
Other: ___________________________________________________
Paracentesis: Therapeutic
Diagnostic: Specify Labs: ________
Abdominal PleurX catheter placement
Cholecystostomy tube placement
Percutaneous transhepatic cholangiogram:
with
w/out biliary drain placement
Percutaneous core liver biopsy Specify Reason: _________________
Transjugular liver biopsy w/ pressure measurements
Transjugular intrahepatic porto systemic shunt (TIPS) placement
T.I.P.S. IR CONSULTATION
Gastric tube placement:
Initial Replacement
Exchange
Gastrojejunostomy tube placement Initial Replace Exchange
Other: __________________________________________________
RENAL:
Percutaneous core renal biopsy ( Native
Transplant)
Nephrostomy tube placement:
Right
Left
Nephroreteral (internal/external) drain placement: Right Left
Double J ureteral stent placement: Right
Left
Super pubic catheter placement
Wire to bladder Nephroreteral catheter placement (Pre-op
nephrolithotripsy):
Right
Left
Other: __________________________________________________
ONCOLOGY:
Biopsy: Specify Organ/Site __________________________________
CT Guided
US Guided
IR Discretion
Bone marrow Biopsy
Chest port:
Initial
Port Check
Removal
Ablation:
Microwave
Radiofrequency Specify Site: ________
Chemoembolization Specify Site: ____________________________
Radioembolization (Y-90) Specify Site: ________________________
Mesentric Angiography w/admin of Tc-99m MMA (pre Y-90)
mapping study
Uterine Fibroid Embolization
IR CONSULTATION: Reason: ________________________________
Other: __________________________________________________
PULMONARY:
Thoracentesis: Therapeutic Diagnostic Specify labs: _________
PleurX Catheter Placement
Chest tube placement
Chemical pleurodesis
Other: __________________________________________________
OTHER/MSK:
DIALYSIS:
Fistulgram:
Diagnostic
with intervention
A/V fistula or Graft declot procedure
Catheter placement:
Temp
Perm: Exchange/Placemt
Conversion of Temp to Perm
Other: _____________________________________________________
FAX ORDER TO: 423-778-6811
Drain placement Specify site: ______________________________
CT Guided
US Guided
IR Discretion
Drain sclerotherapy Specify site of fluid collection: _____________
TPA injection:
Drain
Catheter
Joint steroid injection Specify site: __________________________
Aspiration Specify site: ____________________________________
CT Guided
US Guided
IR Discretion
Professional radiology services provided by:
ERLANGER RADIOLOGY IMAGING REQUEST FORM
Tennessee Interventional and Imaging Associates
Erlanger Baroness Campus
979 E. Third St.
Scheduling: 423-778-5800
East Imaging @ Galen Bldg.
1651 Gunbarrel Rd, Suite 103
Scheduling: 423-778-8976
Erlanger East
1755 Gunbarrel Road, Suite 104
423-778-8471 Walk-in X-rays Avail.
Patient Name:
Date of Birth:
Exam Requested (if not listed below):
Phone #
Erlanger North
632 Morrison Springs Road
Scheduling: 423-778-5800
Appt. Date:
Time:
Diagnosis / ICD-9 Code:
Special Instructions:
Physician Signature:
_____________________________________________________________________________
Printed Physician Name:
___________________________________________________Contact #: _________________
EHS to Schedule Patient
EHS to Precert Patient
Send CD with Patient
Report:
STAT Call Fax To: _______________________________________at: __________________________Ph/Fax #
ULTRASOUND:
PLAIN FILMS:
X-RAY: ___________________________________ (Specify Body Part)
Bone Mineral Density Test (DEXA)
MRI:
(East and Downtown Only)
Contrast at Radiologist discretion unless otherwise indicated.
Brain:
with contrast
w/out
Orbit Protocol
Pituitary Protocol
Cranial Nerve
Stroke Protocol:
with contrast
w/out
MRA Head
MRV Head
MRA Neck:
with contrast
w/out
TMJ
Neck Soft Tissue
Spine:
Cervical
Thoracic
Lumbar
with contrast
w/out
Chest: with contrast
w/out
MRA Chest: with contrast w/out
Body:
Abdomen
Pelvis
MRA ABD/Pelvis with contrast
w/out
Joint: Body Part: ________________________
Right
Left
with Arthrogram
with IV Contrast
Other/Special Instruction:_______________________________________
CT SCAN:
Contrast at Radiologist discretion unless otherwise indicated.
Brain
Maxillofacial (Facial bones)
Paranasal sinus
Temporal bones
Soft tissue neck:
with contrast
w/out
Spine:
Cervical
Thoracic
Lumbar
w/out contrast with
Chest:
w/out contrast
with
include high res
PE Study:
with lower extremity
Screening: CT Thorax low dose
Abdomen and Pelvis
with contrast
w/out
Abdomen Only
with contrast
w/out
Liver Protocol
Adrenal Protocol
Pelvis Only
with contrast
w/out
Enterography
Urography
Extremity: Body Part: ______________________________ Right Left
with IV contrast
w/out
Angiography: Body Part: ____________________________ Right Left
Coronary CT Angiography
Coronary Calcium Score
Other/Special Instructions: _____________________________________
PET/CT SCAN:
(Downtown Location Only)
Body Part: ________________ Specify Reason: _____________________
Abdomen (incl. liver, gallbladder, kidneys, aorta, spleen, pancreas)
w/ Color Doppler
Limited Abdomen (incl. gallbladder and appendix)
Aorta with Color Doppler
Pelvis/Transvaginal/TV with Color Doppler
OB Ultrasound
Kidneys (incl. both sides and Bladder)
Renal arteries with Color/Doppler
Renal transplant with Doppler
SHG
Thyroid
Retroperitoneal (incl. aorta, pancreas, IVC, kidneys, bladder)
Testicles with Color/Doppler
Mesentric Doppler
Liver Doppler (TIPSS Procedure)
Small parts: ___________________________________________
Lower or Upper extremity venous ( Right
Left)
Pediatrics: Baby Head
Other/Special Instruction: _____________________________________
FLUROSCOPIC STUDIES:
(Downtown and North Only)
Esophagram
Upper GI series
w/ small bowel series
Barium Swallow
w/ speech pathologist
Modified Barium Swallow w/ speech pathologist
Lumbar puncture
IVP/Excretory Urogram
Barium enema
w/ air contrast
Myelogram:
Cervical
Thoracic
Lumbar
Cystogram:
Voiding
HSG
Sniff Test
Other/Special Instruction: ____________________________________
NUCLEAR MEDICINE:
(East and Downtown Only)
Myocardial Perfusion Study (Cardiac Stress Test)
Treadmill
Lexiscan/Regodenoson
Bone Scan
with SPECT/CT
HIDA (Gallbladder/Hepatobillary) with stimulation
Thyroid Scan/Uptake
Iodine 131 Therapy
Gastric Empty Study
Dat Scan
Renal Scan
Lung Scan (VQ / Perfusion Only)
Cardiac MUGA
Indium WBC
Indium WBC w/ Bone Scan
MIBG Scan with SPECT/CT
Parathyroid Scan with SPECT/CT
Octreoscan
Professional radiology services provided by:
Tennessee Interventional and Imaging Associates
 Baroness Campus
979 East Third Street
423-778-MAMO (6266)
ERLANGER WOMEN’S IMAGING REQUEST FORM
 East Campus
1751 Gunbarrel Road, Suite G-10
423-778-PINK (7465)
Patient’s Name_________________________________________ DOB ____________ Appointment Date ___________ Time ________
Primary Phone:_________________________________ Secondary Phone:_____________________________
Exam: ________________________________________________________________________________________________________
Diagnosis/ICD-9 Code: __________________________________________________________________________________________
Special Instructions: __________________________________________________________________________________________
Report:  STAT
Call/Fax to (name) ______________________________ Phone ___________________ Fax _________________
 EHS to Schedule Patient
 EHS to Precert Patient
 DEXA Bone Density
 Send CD with Patient
 BREAST ULTRASOUND
Diagnosis: _____________________________________
DEXA Bone Density
 SCREENING MAMMOGRAM - Recommended every 12 months
for women with no sign or symptoms of breast abnormality.
_____ Bilateral _____Unilateral _____Right _____Left
Diagnosis: __________________________________
______ Bilateral ______ Unilateral ______Left _____Right
______ Cancer Risk Counseling – Genetic Counseling
______Cancer Free > 2 Years
______ Breast Self-Exam Instructions
______Bilateral Implants
_______Unilateral Implants
______ Benign Breast Conditions Education
______ Nurse Navigator Consultation
DEXA Bone Density
 DIAGNOSTIC MAMMOGRAM / ULTRASOUND
Circle:
Bilateral
Unilateral
Left
Right
Diagnosis: _______________________________________
______ Malignant neoplasm of breast
______ Abnormal mammogram, follow-up
______ Personal history breast cancer < 2 years
______ Swelling, mass or lump in breast
DEXA Bone Density
______ Breast prosthesis malfunction
 SPECIAL PROCEDURES
______ Breast surgery follow-up
 Image-guided biopsy (core needle)
Clinical Findings: __________________________________
 Cyst aspiration
Left ______ O’Clock
 Breast MRI
______ Quadrant
Right ______ O’Clock
 OTHER: _________________________
______ Quadrant
Comments: ______________________________________
 Schedule for surgical consultation if the Radiologist
________________________________________________
finds it is appropriate
________________________________________________
Surgeon of choice: _____________________________
Physician’s Signature: __________________________________________ Contact Name: ___________________________________
Print Physician’s Name: __________________________________________ Phone: ___________________ Fax: _________________
Has patient had a previous mammogram?
 Yes  No
Date: __________________ Location: _______________________________
It’s important to bring comparison mammograms with you on day of exam if last done at a facility outside Erlanger Health
System.
Erlanger Breast Center
Patient Identification