CT Scan Scheduling CT Scan Scheduling In order to process the appointment, please complete all of the information below. A coordinator will schedule an appointment as quickly as possible. Please ensure the accuracy of the information provided.Patient Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Primary Phone(Required)Secondary PhoneRequesting Physician/Provider(Required) Physician Full Name Clinic Contact Name(Required) Full NamePhysician/Clinic Phone(Required)Authorization Number(Required) Insurance(Required) Insurance Policy Number(Required) Procedure(Required)CT Abd Pelvis W ConCT Abd Pelvis with IV ConCT Abd Pelvis with IV ConCT Abd Pelvis WW ConCT Abd WIV ConCT Abd WIV Oral ConCT Abd WOral Con OnlyCT Abd WOral Con OnlyCT Abd WWO ConCT Chest ABD Pel W ConCT Chest ABD Pel WWOCT Chest Super DCT Chest W ConCT Chest Wo ConCT Chest WWO ConCT CSpine W ConCT CSpine WWO ConCT Double W ConCT Double WWO ConCT Facial Bones W ConCT Facial Bones WO ConCT Facial Bones WWO ConCT Head W ConCT Head WWO ConCT Heart Calcium ScoreCT IAC W ConCT IAC WWO ConCT Lower Ext W ConCT Lower Ext WWO ConCT LSpine W ConCT LSpine WWO ConCT Mako KneeCT Orbits W ConCT Orbits WWO ConCT Pelvis WIV Con OnlyCT Pelvis WIV Oral ConCT Pelvis WOral Con OnlyCT Pelvis WWO ConCT Sinuses W Con (Right/Left/Bilateral)CT Sinuses WWO Con (Right/Left/Bilateral)CT Soft Tis Neck W Con (Right/Left/Bilateral)CT Soft Tis Neck WO Con (Right/Left/Bilateral)CT Soft Tis Neck WWO Con (Right/Left/Bilateral)CT Triple W ConCT Triple WWO ConCT TSpine W ConCT TSpine WWO ConCT Upper Ext W ConCT Upper Ext WWO ConCTA ABD AOR BIL RUN WWOCTA Abd WWO ConCTA CarotidsCTA Chest WWO ConCTA Chest WWO ConCTA HeartCTA Low Ext WWO ConCTA Neck WWO ConCTA Pelvis WWO ConCTA Upper Ext WWO ConDiagnosis Code(Required) Appropriate Use Criteria G Code Is the patient over 60 years old?(Required) Yes No Does the patient have an allergy to Iodine?(Required) Yes No Unsure Is this for a PE, Aorta or Coronary?(Required) Yes No Unsure Additional Procedure (If Applicable)No Additional ProcedureCT Abd Pelvis W ConCT Abd Pelvis with IV ConCT Abd Pelvis with IV ConCT Abd Pelvis WW ConCT Abd WIV ConCT Abd WIV Oral ConCT Abd WOral Con OnlyCT Abd WOral Con OnlyCT Abd WWO ConCT Chest ABD Pel W ConCT Chest ABD Pel WWOCT Chest Super DCT Chest W ConCT Chest Wo ConCT Chest WWO ConCT CSpine W ConCT CSpine WWO ConCT Double W ConCT Double WWO ConCT Facial Bones W ConCT Facial Bones WO ConCT Facial Bones WWO ConCT Head W ConCT Head WWO ConCT Heart Calcium ScoreCT IAC W ConCT IAC WWO ConCT Lower Ext W ConCT Lower Ext WWO ConCT LSpine W ConCT LSpine WWO ConCT Mako KneeCT Orbits W ConCT Orbits WWO ConCT Pelvis WIV Con OnlyCT Pelvis WIV Oral ConCT Pelvis WOral Con OnlyCT Pelvis WWO ConCT Sinuses W Con (Right/Left/Bilateral)CT Sinuses WWO Con (Right/Left/Bilateral)CT Soft Tis Neck W Con (Right/Left/Bilateral)CT Soft Tis Neck WO Con (Right/Left/Bilateral)CT Soft Tis Neck WWO Con (Right/Left/Bilateral)CT Triple W ConCT Triple WWO ConCT TSpine W ConCT TSpine WWO ConCT Upper Ext W ConCT Upper Ext WWO ConCTA ABD AOR BIL RUN WWOCTA Abd WWO ConCTA CarotidsCTA Chest WWO ConCTA Chest WWO ConCTA HeartCTA Low Ext WWO ConCTA Neck WWO ConCTA Pelvis WWO ConCTA Upper Ext WWO ConDiagnosis Code(Required) Appropriate Use Criteria G Code Is the patient over 60 years old?(Required) Yes No Does the patient have an allergy to Iodine?(Required) Yes No Unsure Is this for a PE, Aorta or Coronary?(Required) Yes No Unsure Additional Procedure 2 (If Applicable)No Additional ProcedureCT Abd Pelvis W ConCT Abd Pelvis with IV ConCT Abd Pelvis with IV ConCT Abd Pelvis WW ConCT Abd WIV ConCT Abd WIV Oral ConCT Abd WOral Con OnlyCT Abd WOral Con OnlyCT Abd WWO ConCT Chest ABD Pel W ConCT Chest ABD Pel WWOCT Chest Super DCT Chest W ConCT Chest Wo ConCT Chest WWO ConCT CSpine W ConCT CSpine WWO ConCT Double W ConCT Double WWO ConCT Facial Bones W ConCT Facial Bones WO ConCT Facial Bones WWO ConCT Head W ConCT Head WWO ConCT Heart Calcium ScoreCT IAC W ConCT IAC WWO ConCT Lower Ext W ConCT Lower Ext WWO ConCT LSpine W ConCT LSpine WWO ConCT Mako KneeCT Orbits W ConCT Orbits WWO ConCT Pelvis WIV Con OnlyCT Pelvis WIV Oral ConCT Pelvis WOral Con OnlyCT Pelvis WWO ConCT Sinuses W Con (Right/Left/Bilateral)CT Sinuses WWO Con (Right/Left/Bilateral)CT Soft Tis Neck W Con (Right/Left/Bilateral)CT Soft Tis Neck WO Con (Right/Left/Bilateral)CT Soft Tis Neck WWO Con (Right/Left/Bilateral)CT Triple W ConCT Triple WWO ConCT TSpine W ConCT TSpine WWO ConCT Upper Ext W ConCT Upper Ext WWO ConCTA ABD AOR BIL RUN WWOCTA Abd WWO ConCTA CarotidsCTA Chest WWO ConCTA Chest WWO ConCTA HeartCTA Low Ext WWO ConCTA Neck WWO ConCTA Pelvis WWO ConCTA Upper Ext WWO ConDiagnosis Code(Required) Appropriate Use Criteria G Code Is the patient over 60 years old?(Required) Yes No Does the patient have an allergy to Iodine?(Required) Yes No Unsure Is this for a PE, Aorta or Coronary?(Required) Yes No Unsure Additional Procedure 3 (If Applicable)No Additional ProcedureCT Abd Pelvis W ConCT Abd Pelvis with IV ConCT Abd Pelvis with IV ConCT Abd Pelvis WW ConCT Abd WIV ConCT Abd WIV Oral ConCT Abd WOral Con OnlyCT Abd WOral Con OnlyCT Abd WWO ConCT Chest ABD Pel W ConCT Chest ABD Pel WWOCT Chest Super DCT Chest W ConCT Chest Wo ConCT Chest WWO ConCT CSpine W ConCT CSpine WWO ConCT Double W ConCT Double WWO ConCT Facial Bones W ConCT Facial Bones WO ConCT Facial Bones WWO ConCT Head W ConCT Head WWO ConCT Heart Calcium ScoreCT IAC W ConCT IAC WWO ConCT Lower Ext W ConCT Lower Ext WWO ConCT LSpine W ConCT LSpine WWO ConCT Mako KneeCT Orbits W ConCT Orbits WWO ConCT Pelvis WIV Con OnlyCT Pelvis WIV Oral ConCT Pelvis WOral Con OnlyCT Pelvis WWO ConCT Sinuses W Con (Right/Left/Bilateral)CT Sinuses WWO Con (Right/Left/Bilateral)CT Soft Tis Neck W Con (Right/Left/Bilateral)CT Soft Tis Neck WO Con (Right/Left/Bilateral)CT Soft Tis Neck WWO Con (Right/Left/Bilateral)CT Triple W ConCT Triple WWO ConCT TSpine W ConCT TSpine WWO ConCT Upper Ext W ConCT Upper Ext WWO ConCTA ABD AOR BIL RUN WWOCTA Abd WWO ConCTA CarotidsCTA Chest WWO ConCTA Chest WWO ConCTA HeartCTA Low Ext WWO ConCTA Neck WWO ConCTA Pelvis WWO ConCTA Upper Ext WWO ConDiagnosis Code(Required) Appropriate Use Criteria G Code Is the patient over 60 years old?(Required) Yes No Does the patient have an allergy to Iodine?(Required) Yes No Unsure Is this for a PE, Aorta or Coronary?(Required) Yes No Unsure Additional Procedure 4 (If Applicable)No Additional ProcedureCT Abd Pelvis W ConCT Abd Pelvis with IV ConCT Abd Pelvis with IV ConCT Abd Pelvis WW ConCT Abd WIV ConCT Abd WIV Oral ConCT Abd WOral Con OnlyCT Abd WOral Con OnlyCT Abd WWO ConCT Chest ABD Pel W ConCT Chest ABD Pel WWOCT Chest Super DCT Chest W ConCT Chest Wo ConCT Chest WWO ConCT CSpine W ConCT CSpine WWO ConCT Double W ConCT Double WWO ConCT Facial Bones W ConCT Facial Bones WO ConCT Facial Bones WWO ConCT Head W ConCT Head WWO ConCT Heart Calcium ScoreCT IAC W ConCT IAC WWO ConCT Lower Ext W ConCT Lower Ext WWO ConCT LSpine W ConCT LSpine WWO ConCT Mako KneeCT Orbits W ConCT Orbits WWO ConCT Pelvis WIV Con OnlyCT Pelvis WIV Oral ConCT Pelvis WOral Con OnlyCT Pelvis WWO ConCT Sinuses W Con (Right/Left/Bilateral)CT Sinuses WWO Con (Right/Left/Bilateral)CT Soft Tis Neck W Con (Right/Left/Bilateral)CT Soft Tis Neck WO Con (Right/Left/Bilateral)CT Soft Tis Neck WWO Con (Right/Left/Bilateral)CT Triple W ConCT Triple WWO ConCT TSpine W ConCT TSpine WWO ConCT Upper Ext W ConCT Upper Ext WWO ConCTA ABD AOR BIL RUN WWOCTA Abd WWO ConCTA CarotidsCTA Chest WWO ConCTA Chest WWO ConCTA HeartCTA Low Ext WWO ConCTA Neck WWO ConCTA Pelvis WWO ConCTA Upper Ext WWO ConDiagnosis Code(Required) Appropriate Use Criteria G Code Is the patient over 60 years old?(Required) Yes No Does the patient have an allergy to Iodine?(Required) Yes No Unsure Is this for a PE, Aorta or Coronary?(Required) Yes No Unsure EmailThis field is for validation purposes and should be left unchanged.