Radiological Procedure Requisition - St. Anthony's Medical Center

St. Anthony’s Medical Center • St. Louis, Missouri 63128RADIOLOGICAL PROCEDURE REQUISITIONPATIENTIName (last, first, middle initial) ________________________________________________________Birthdate ____________ Sex _____ Social Security Number ______________________________Patient/Insured’s Address ____________________________________________________________________________________________________________________________________________Patient’s Phone Number ( _____________ ) _____________________________________________Patient’s Work Number ( _____________ ) _____________________________________________Patient Instructions: Please bring this form with you. Your current insurance card must be presented at the time of registration.PHYSICIANDT0301All appointments should be scheduled by calling 314.525-1300 or 800.991-7262. All requistions faxed to 314.525-1329.To schedule Nuclear Medicine exams please call 314.525-1170.Scheduling office hours: St. Anthony’s Radiology Department St. Anthony’s Breast Center St. Anthony’s Imaging CenterMonday through Friday (Hospital) (Medical Plaza) (Medical Plaza)7:30 AM - 6:30 PM 10010 Kennerly Road 12700 Southfork Road, Suite 153 12700 Southfork Road, Suite 151314.525.1155 314.525.3400 314.525.4700Arnold Urgent Care Big Bend Urgent Care Fenton Urgent Care Lemay Urgent Care3619 Richardson Square Drive 10296 Big Bend Boulevard 714 Gravois Road 2900 Lemay Ferry RoadArnold, MO 63010 St. Louis, MO 63122 Fenton, MO 63026 St. Louis, MO 63125636.464.4660 314.543.5970 636.326.6100 314.543.5294Ordering Physician Name_____________________________________________________________Physician’s Phone Number ( ___________ ) _____________________________________________Physician’s Fax Number ( ____________ ) _____________________________________________________________________________________________________________________________________________________________________________________________________________NSURANCEPre-certifi cation Number ___________________________________________________________DIAGNOSIS ICD-9-CM APPOINTMENT DATE TIME AMPMALLERGIESNOTE: A DIAGNOSIS (ICD-9) CODE IS REQUIRED FOR EVERY TEST ORDERED.TESTS / PROCEDURESTESTICD-9-CMTESTICD-9-CMTESTICD-9-CMChest, P.A. and lateralChest, single viewChest, decubitus, rightChest, decubitus, leftVolume Rad (Imaging Center-Plaza Only)Facial bonesSinusSpine, cervicalSpine, thoracicSpine, lumbarSacrum and coccyxPelvisClavicle, rightClavicle, leftShoulder, rightShoulder, leftHumerus, rightHumerus, leftElbow, rightElbow, leftForearm, rightForearm, leftRibs, leftHip, rightHip, leftFemur, rightFemur, leftKnee, rightKnee, leftTibia/Fibula, rightTibia/Fibula, leftAnkle, rightAnkle, leftFoot, rightFoot, leftAbdomen, KUBLower GIAir contrast, lower GIGallbladderSmall bowel seriesUGIAir contrast, upper GIBarium swallowBarium swallow, modifi edUltrasound (specify exam):CT (specify exam):With contrast ✽Without contrastWith/Without contrastNuclear medicine (specify exam):Specify procedures (specifyexam): ✽Bone densityOther (specify exam):Breast Exams:Screening MammogramDiagnostic MammogramBilateralWrist, rightIVP ✽Unilateral - Right LeftWrist, leftHand, rightHand, leftFinger, rightFinger, leftRibs, rightOtherMRI (specify exam):(Fenton and ImagingOPEN MRI Center only)With contrast ✽Without contrastWith/Without contrastBreast UltrasoundBiopsy if needed03 MD ORDERSPhysician’s signature ___________________________________________________ Date _________________________ Time ______________(required)PMM-59713 (REV 08/09)*SEE WARNINGON REVERSE SIDESEE MAPS ON REVERSE SIDE