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fomedix
Mobile Medical Imaging Service
(704) 287-8219
info@formedix.com
www.fomedix.com
X-RAY
ULTRASOUND
EKG
MOBILE IMAGING
provider order form
PROVIDER INFO & SIGNATURE
Provider Name:
NPI Number:
Phone:
Fax:
Email:
Address:
Signature:
Date:
Time:
PATIENT INFORMATION
Patient Name:
DOB:
Gender:
M
F
Phone:
Address:
City:
ST:
ZIP:
Self Paid Patient
ORDER INFORMATION
iCD / 10 Code
Priority:
ROUTINE
STAT
Clinical Indication / Reason for Exam:
Please Select Type of Study(ies) Ordered:
H
X-RAY
Please check all that apply.
Facial Bones
Nasal Bone
Chest & Thoracic
Chest (PA & Lateral)
Chest (Single View)
Ribs - Left
Ribs - Right
Bilateral Ribs
Abdomen (KUB)
Abdomen (Acute Series)
Spine
Cervical:
3 views
Complete
Thoracic:
Complete
Lumbar:
2 views
Complete
Sacrum/Coccyx:
Complete
Pelvic
Pelvis (AP)
Hip
Right
Left
Bilateral
Sacroiliac Joints
Upper Extremities
L
R
Shoulder
Scapula
Humerus
Elbow
Forearm
Wrist
Hand
Finger
Lower Extremities
L
R
Femur
Knee
Tibia & Fibula
Ankle
Foot
Toe
Other:
U
ULTRASOUND
Please check all that apply.
Abdomen
Complete
Limited (RUQ)
Renal Kidney Bladder Complete
W/Pre and Post Voiding
Prostate
Pelvis Complete (W/Pre and Post Voiding)
Prostate
TA
TV
W/Doppler
Scrotum and Testicle
W/Doppler
Head and Neck Soft Tissue
Thyroid
Thyroid/Parathyroid
Soft Tissue/Mass
Abdominal Aorta
Carotid Duplex Doppler Complete
Arterial Upper Extremity Duplex:
Right
Left
Bilateral
Arterial Lower Extremity Duplex:
Right
Left
Bilateral
Venous Upper Extremity Duplex:
Right
Left
Bilateral
Venous Lower Extremity Duplex:
Right
Left
Bilateral
Abdominal Appendix
OB Ultrasound:
Less than 14 Weeks
More than 14 Weeks
E
EKG
Check option below.
12-Lead EKG
Clinical Information
(Relevant history, symptoms, or diagnosis)
assignment
Patient Instructions
Wear simple, comfortable clothing.
Remove all underwear / bras (for X-ray/EKG).
Remove all necklaces and jewelry if possible.
Remove piercings if possible.
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Send Order