Diagnostic Radiology Scheduling Diagnostic Radiology 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)Arthrogram AnkleArthrogram ElbowArthrogram HipArthrogram KneeArthrogram ShoulderArthrogram WristBarium EnemaBarium Enema With AirBone Den Hip Pelv SpineBone Den Rad Wrist HeelCholangiogramCholangiogram-T-TubeCystogram 3 ViewsEsophagus RoutineGastrografin EnemaHysterosalpingogramIVPLoop O GramMetastatic Bone SurveyModified Barium SwallowMyelogram CervicalMyelogram LumbarMyelogram ThoracicNephrostogramSmall Bowel StudyUGI With Air W Sm BowelUGI With Air With ScoutUGI With Air WO ScoutUGI With ScoutUGI With Small BowelUGI WO ScoutUrethrocystogram VoidingDiagnosis Code(Required) Is the patient over 50 years old?(Required) Yes No Is the patient allergic to Iodine?(Required) Yes No Unsure Patient must pick up prep and instructions from the Radiology department the day before the exam. A bowel prep is required.Has the patient had CT contrast in the past 7 days?(Required) Yes No When in the past 7 days did the patient have CT contrast?(Required) MM slash DD slash YYYY This procedure needs to be scheduled out 7 days from when contrast was given. Additional Procedure (If Applicable)No Additional ProcedureArthrogram AnkleArthrogram ElbowArthrogram HipArthrogram KneeArthrogram ShoulderArthrogram WristBarium EnemaBarium Enema With AirBone Den Hip Pelv SpineBone Den Rad Wrist HeelCholangiogramCholangiogram-T-TubeCystogram 3 ViewsEsophagus RoutineGastrografin EnemaHysterosalpingogramIVPLoop O GramMetastatic Bone SurveyModified Barium SwallowMyelogram CervicalMyelogram LumbarMyelogram ThoracicNephrostogramSmall Bowel StudyUGI With Air W Sm BowelUGI With Air With ScoutUGI With Air WO ScoutUGI With ScoutUGI With Small BowelUGI WO ScoutUrethrocystogram VoidingDiagnosis Code(Required) Is the patient over 50 years old?(Required) Yes No Is the patient allergic to Iodine?(Required) Yes No Unsure Patient must pick up prep and instructions from the Radiology department the day before the exam. A bowel prep is required.Has the patient had CT contrast in the past 7 days?(Required) Yes No When in the past 7 days did the patient have CT contrast?(Required) MM slash DD slash YYYY This procedure needs to be scheduled out 7 days from when contrast was given. Additional Procedure 2 (If Applicable)No Additional ProcedureArthrogram AnkleArthrogram ElbowArthrogram HipArthrogram KneeArthrogram ShoulderArthrogram WristBarium EnemaBarium Enema With AirBone Den Hip Pelv SpineBone Den Rad Wrist HeelCholangiogramCholangiogram-T-TubeCystogram 3 ViewsEsophagus RoutineGastrografin EnemaHysterosalpingogramIVPLoop O GramMetastatic Bone SurveyModified Barium SwallowMyelogram CervicalMyelogram LumbarMyelogram ThoracicNephrostogramSmall Bowel StudyUGI With Air W Sm BowelUGI With Air With ScoutUGI With Air WO ScoutUGI With ScoutUGI With Small BowelUGI WO ScoutUrethrocystogram VoidingDiagnosis Code(Required) Is the patient over 50 years old?(Required) Yes No Is the patient allergic to Iodine?(Required) Yes No Unsure Patient must pick up prep and instructions from the Radiology department the day before the exam. A bowel prep is required.Has the patient had CT contrast in the past 7 days?(Required) Yes No When in the past 7 days did the patient have CT contrast?(Required) MM slash DD slash YYYY This procedure needs to be scheduled out 7 days from when contrast was given. Additional Procedure 3 (If Applicable)No Additional ProcedureArthrogram AnkleArthrogram ElbowArthrogram HipArthrogram KneeArthrogram ShoulderArthrogram WristBarium EnemaBarium Enema With AirBone Den Hip Pelv SpineBone Den Rad Wrist HeelCholangiogramCholangiogram-T-TubeCystogram 3 ViewsEsophagus RoutineGastrografin EnemaHysterosalpingogramIVPLoop O GramMetastatic Bone SurveyModified Barium SwallowMyelogram CervicalMyelogram LumbarMyelogram ThoracicNephrostogramSmall Bowel StudyUGI With Air W Sm BowelUGI With Air With ScoutUGI With Air WO ScoutUGI With ScoutUGI With Small BowelUGI WO ScoutUrethrocystogram VoidingDiagnosis Code(Required) Is the patient over 50 years old?(Required) Yes No Is the patient allergic to Iodine?(Required) Yes No Unsure Patient must pick up prep and instructions from the Radiology department the day before the exam. A bowel prep is required.Has the patient had CT contrast in the past 7 days?(Required) Yes No When in the past 7 days did the patient have CT contrast?(Required) MM slash DD slash YYYY This procedure needs to be scheduled out 7 days from when contrast was given. Additional Procedure 4 (If Applicable)No Additional ProcedureArthrogram AnkleArthrogram ElbowArthrogram HipArthrogram KneeArthrogram ShoulderArthrogram WristBarium EnemaBarium Enema With AirBone Den Hip Pelv SpineBone Den Rad Wrist HeelCholangiogramCholangiogram-T-TubeCystogram 3 ViewsEsophagus RoutineGastrografin EnemaHysterosalpingogramIVPLoop O GramMetastatic Bone SurveyModified Barium SwallowMyelogram CervicalMyelogram LumbarMyelogram ThoracicNephrostogramSmall Bowel StudyUGI With Air W Sm BowelUGI With Air With ScoutUGI With Air WO ScoutUGI With ScoutUGI With Small BowelUGI WO ScoutUrethrocystogram VoidingDiagnosis Code(Required) Is the patient over 50 years old?(Required) Yes No Is the patient allergic to Iodine?(Required) Yes No Unsure Patient must pick up prep and instructions from the Radiology department the day before the exam. A bowel prep is required.Has the patient had CT contrast in the past 7 days?(Required) Yes No When in the past 7 days did the patient have CT contrast?(Required) MM slash DD slash YYYY This procedure needs to be scheduled out 7 days from when contrast was given. CommentsThis field is for validation purposes and should be left unchanged.