Imaging Requisition | Gillespie Wellness

Patient & Order Information

Patient name

Date of birth

Patient phone

Patient email (for the email option below)

Date of order

Preferred imaging facility (optional)

Requesting provider

Provider license / NPI

Phone report requested?

Yes No

Films requested?

Yes No

Preliminary diagnosis (required to satisfy third-party payers)

Diagnostic Radiology

Note: BUN and Creatinine levels must be done and called into the imaging office prior to an IVP exam.

Ultrasound

CT Scan

Study	w/ contrast	w/o contrast
Brain, Routine
Pituitary
Brain w/ Posterior Fossa
Temporal Bones / Mastoids
Orbits
Maxillo-Facial / Sinuses
Neck — Soft Tissues
Larynx
Chest
Abdomen
Pelvis
Cervical Spine
Thoracic Spine
Lumbar Spine L3–S1
Lumbar Spine, entire segment
Upper Extremity RL
Lower Extremity RL

Specify levels / additional CT detail

Bone Densitometry

Specify

Other Orders

Anything not listed above

Note to requesting provider: To satisfy third-party payers, all requests for examinations must include a diagnosis related to the individual patient. In many instances pre-certification or pre-authorization is required by the patient's insurer; exams may not be performed without the necessary authorization numbers submitted prior to the appointment.

Ordering provider signature

Date