Download RX Form - Total Imaging Centers

YOU MUST HAVE THIS FORM FOR EXAM TO BE COMPLETED.
For scheduling at all locations, please call (813) 661-1060 or Fax to (813) 655-3172.
www.totalimagingcenters.com
 Total-Sun City Center
 Total-Parsons
3862 Sun City Center Blvd.
427 S. Parsons Ave., Ste. 100
Sun City Center, FL 33573
Brandon, FL 33511
Phone (813) 642-9299
Phone (813) 315-2080
PA R S O N S - S U N C I T Y
Fax (813) 633-3565
Fax (813) 315-2090
NPI # 1710088919
NPI # 1871781088
Tax ID # 20-0973385
Tax ID # 75-3246956
 Fax STAT Report to: (___)___________
This exam is medically necessary for this patient.
 CD
See reverse side for important information.
MRI
w/o contrast
w/ & w/o contrast
Breast
Brain
Orbits
TMJ
Cervical Spine
Thoracic Spine
Lumbar Spine
Neck Soft Tissue
Shoulder R:___ L:___
Elbow
R:___ L:___
Wrist
R:___ L:___
Hip
R:___ L:___
Knee
R:___ L:___
Ankle
R:___ L:___
Arthrogram-specify joint:______________
Other: specify
Abdomen
MRCP
Liver-specify indication __________
Other-specify indication __________
Pelvis
MRA ANGIOGRAPHY
MRA / Head (Circle of Willis)
MRA / Renal
MRA / Carotid
Aorta w/Extremity Runoff
Abdominal-Aorta
Thoracic-Aorta
Other ___________________________
MAMMOGRAPHY
(Total Imaging- Parsons & Sun City)
Please bring previous films
Screening
Screening (Diag. and/or U/S if indicated)
Bilateral Diag. ___U/S if indicated
Unilateral Diag. ___U/S if indicated
BREAST BIOPSY
Biopsies performed at Total Parsons
Biopsy to be determined by radiologist
Ultrasound Guided
MR Guided
FLUOROSCOPY
NUCLEAR MEDICINE
(Total Imaging- Parsons )
Barium Enema / Air
UGI
UGI with Small Bowel
Small Bowel Series
Esophogram
Voiding Cystogram
IVP
IVP w/Tomography
CT
w/o ____ w/&w/o ____
Brain
w/o ____ w/&w/o ____
Orbits
w/o ____
Sinus
w/o ____ w/_____
Maxillofacial
Mastoids/Temporal w/o ____ w/&w/o ____
bones
w/______
Neck
w/o ____ w/______
Chest / Thorax
w/o ____ w/&w/o ____
Abdomen
w/o ____ w/ _____
Pelvis
Renal Stone Protocol
(Abd. & Pelvis w/o contrast)
w/&w/o ____
CT Urogram - (Abd & Pelvis)
w/o ____
Cervical Spine w/MPR
w/o ____
Thoracic Spine w/MPR
w/o ____
Lumbar Spine w/MPR
w/o ____
Upper Extremity w/MPR
Specify__________________
Lower Extremity w/MPR
w/o ____
Specify_________________
CTA ANGIOGRAPHY
All CTA’s performed with IV Contrast
CTA Brain- (COW)
CTA Neck - (Carotids)
CTA Chest - Pulmonary Emboli Protocol
CTA Chest - Thoracic Aorta
CTA Aorta - w/Runoff
CTA - Abdomen
CTA - Pelvis
Extremities
Upper Lower Specify
PET / CT IMAGING*
Indication:_________________________
Initial Treatment
Subsequent Treatment
PET - Brain
PET/CT - Skull Base to Mid-Thigh
PET/CT - Melanoma (Whole Body)
PET/CT - Bone Imaging (NaF)
PET/CT - w/Dual Time Delayed
PET/CT - w/Super Dimension
Bone Scan-Whole Body
Bone - Limited_____________
Bone - 3 Phase ____________
Hida Scan - w/ Ejection Fraction
Gastric Empty Study
Parathyroid Scan
Liver Spleen Scan
Thyroid Scan with Uptake
Thyroid Scan w/ 6+ 24 Hr Uptakes
MUGA Scan
Renal Scan (Baseline)
Renal Scan (Lasix)
Renal Scan (Vasotec)
DMSA Renal
White Blood Cell Scan
Other:_
_________________
ULTRASOUND
Abdominal Total
Appendix
RUQ (includes gallbladder,
pancreas, liver & right kidney)
Renal
Aorta
Transabdominal & Transvaginal Pelvis
Pelvis Transabdominal Only
Pelvis Transvaginal Only
Obstetrical
Hysterosonogram
Carotid (Duplex scan)
Thyroid
Scrotal with Color Doppler
Breast Sono R:___L:___
Venous Duplex
R: ____ L:____ Bilateral____
Upper Ext._____ Lower Ext._____
Arterial Duplex w/Physiologic Testing
R: ____ L:____ Bilateral____
Upper Ext._____ Lower Ext._____
Echo w/Color Flow/Doppler
Renal Dopplar
Physician’s Notes / Other Procedures
SPECIAL PROCEDURES
Myelogram w/CT
C-Spine
T-Spine
L-Spine
Hysterosalpingogram
Arthrogram: Joint ______________
Arthrogram w/MRI
Arthrogram w/CT
EKG
Bone Densitometry (DEXA)
Cardiac Scoring (Heart Scan)
GENERAL RADIOLOGY
CXR
KUB
Abdomen Complete
Ribs
R:___
Bone Age
Skull
Sinus / Waters 1 view
Sinus Series
Neck Soft Tissue
TMJ Bilateral
C-Spine
T-Spine
L-Spine
Clavicle
R:___
Shoulder
R:___
Humerus
R:___
Elbow
R:___
Forearm
R:___
Wrist
R:___
Hand
R:___
Finger
R:___
Pelvis
Hips
R:___
Femur
R:___
Knee
R:___
Tib/Fib
R:___
Ankle
R:___
Foot
R:___
Toe
R:___
Other___________ R:___
L:___
L:___
L:___
L:___
L:___
L:___
L:___
L:___
L:___
L:___
L:___
L:___
L:___
L:___
L:___
L:___
L:___
* Detailed Clinical History Required:
Patient’s Name
Clinical History/DX
Appointment Date
Physician’s Name
Appointment Time
Physician’s Signature
Date
TIP05002 Rev. 03/2014
Important Insurance Information
If your insurance company requires a referral or authorization number for diagnostic testing, YOU MUST have the referral or authorization number with
you at the time of your exam. If you arrive for your exam without this information, we will attempt to get the referral/authorization number from your
physician’s office or insurance company, but pleaseImportant
realize THATInsurance
YOUR EXAMInformation
MAY HAVE TO BE RESCHEDULED. Thank you for your cooperation.
If your insurance company requires a referral or authorization number for diagnostic testing, YOU MUST have the referral or authorization number with you
at the time of your exam. If you arrive for your exam without this information, we will attempt to get the referral/authorization number from your physician’s
Si su compania
de seguro requiere que tenga un referido o numero de autorizacion para un examen de diagnostico, USTED TIENE que tener el referido o el
office or insurance company, but please realize THAT YOUR EXAM MAY HAVE TO BE RESCHEDULED. Thank you for your cooperation.
numero de autorizacion al momento de hacerse el examen. Si usted llega a su examen sin esta informacion, haremos el intent de obtener el referido o
su compania dede
seguro
requiere de
que su
tenga
un referido
numero de Siautorizacion
la oficina
medico
o. o numero de autorizacion para un examen de diagnostico, USTED TIENE que tener el referido o el
numero de autorizacion al momento de hacerse el examen. Si usted llega a su examen sin esta informacion, haremos el intent de obtener el referido o numero
de autorizacion de la oficina de su medico o.
Directions
Total Imaging Parsons Directions Total Imaging Sun City
3862 Sun City Center
Boulevard
427 S. Parsons1 Tower
Avenue,Diagnostic
Suite 100 Center of Brandon 2 Total Imaging Parsons
3 Total
Imaging Sun City
From Brandon613
Blvd.
takeDrive,
Parsons
Avenue South.
1½Sun
miles,
go left
at second light.
Oakfield
Brandon
427 S. Parsons Avenue, SuiteOff
100of I-75 head east3862
City Center
Boulevard
From
Brandon
Blvd.,
take
Kings
Avenue
South.
From
Brandon
Blvd.
take
Parsons
Avenue
South.
Off
of
I-75
head
east
1½
miles, go
left at
Building
After crossing over Oakfield Drive, make a left into Brandon Medical Plaza. The office is located behind the BB&T Bank
After crossing over Oakfield Drive, make a left into
At the second street (Oakfield), turn left.
second light. The office is located behind the
We are locatedWeinareSuite
100 building on your right.
Brandon Medical Plaza. We are located in Suite 100.
1
the second
BB&T Bank Building.
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Contrast
Criteria
Contrast
Criteria
Bun/Creatinine levels will be requested if test is ordered with contrast and patient falls under one of the following criteria:
levels will be requested if test is ordered with contrast and patient falls under one of the following criteria:
Bun/Creatinine
MRI (labs must be performed within 3 months of procedure)
CT/IVP/Venogram (labs must be performed within 6 months of procedure)
MRI (labs must be performed
within 3 months
of procedure)
CT/IVP/Venogram
(labs• must
be performed within 6 months of procedure)
• Kidney disease
• Diabetic
• 65 Years of age or older
Nephrectomy
• Kidney disease • Diabetic• Hypertension • Liver transplant
• 65• Kidney
Yearsdisease
of age or older • Insulin• Nephrectomy
dependent diabetic
*If
patient
is
86
years
of
age
and
fall
into
one
or
more
of
the
above
criteria,
we
• Hypertension • Liver transplant
• Insulin dependent diabetic
• Kidney disease
will request a 24 hour urine creatinine clearance test performed within 6 weeks of
*If patient is 86
years
of
age
and
fall
into
one
or
more
of
the
above
criteria,
procedure. If patient is on dialysis, please contact our office for specific requirements.
we will request a 24 hour urine creatinine clearance test performed within
Exam Preparation
6 weeks of procedure. If patient is on dialysis, please contact our office for
Please arrive 20 to 30 minutes prior to your scheduled appointment to allow time to fill out the necessary forms. It is important that you bring any previous films relating
specific requirements.
to your exam (if outside Tower/Total Diagnostic Centers) so that our doctors can properly evaluate your results. For your convenience, we have Spanish speaking employees.
and your test.Preparation
Please contact the facility if you have any questions regarding medicationsExam
Myelograms, Hysterosalpingograms: Please call the center for special
Barium Enema (BE), IVP Exams: Use the prep kit the day before the exam
20Scans,
to 30
minutes prior to your scheduled appointment to allow
time to fill out the necessary forms. It is important that you bring any previous
Please arriveCAT
instructions.
following the directions carefully. These tests require special instructions. The prep
films relating
your examHysterosalpingograms:
(if outside Tower/Total Diagnostic Centers) so that
our
doctors
properly
evaluate
your Centers.
results. For your convenience, we have
CAT,toMyelograms,
kits are
available
from can
your doctor,
or Tower/Total
Diagnostic
(Por favor llame al consultario para instrucciones especiales.)
Barium Enema (BE), IVP Exams: (Use el prep kit el día antes del
Spanish speaking employees. Please contact the facility if you have any questions
regarding medications and your test.
examen siguiendo cuidadosamente las instrucciones. Estos examenes requieren
Ultrasound: Drink
1 quart of liquid 1 hour before exam
and docall
NOT use
especiales.
El prep(BE),
kit esta IVP
disponible
por medio
su medico
por the day before the exam
CAT Scans,Pelvic
Myelograms,
Hysterosalpingograms:
Please
thethecenterinstrucciones
Barium
Enema
Exams:
Usedethe
prepo kit
los consultorios de Tower/Total Diagnostic Centers.)
bathroom. Your bladder must remain full for the exam.
for special instructions.
following
the
directions
carefully.
These
tests
require
special instructions.
Ultrasonido de la Vesicula: (Beba 1 quarto de liquido una hora antes del examen
CAT, Myelograms,
Hysterosalpingograms:
prepSeries,
kits Gallbladder,
are available
from
your Ultrasound
doctor, orExams:
Tower/Total Diagnostic
y NO use el bano.
Debe mantener la vesicula llena para el examen.)
UpperThe
GI (UGI)
Liver,
Pancreas
Do NOT eat or drink anything from midnight the night before your exam until the
(Por favor llame
al consultario para instrucciones especiales.)
Centers.
exam is complete.
Mammograms: Do NOT use deodorant, powders, or perfume on day of exam.
Pelvic Ultrasound:
Drink
1
quart
of
liquid
1
hour
before
exam
and
do
NOT
Enema
(BE), IVP
el prep kit el día antes del
UpperBarium
GI (UGI) Series,
Gallbladder,
Liver,Exams:
Pancreas(Use
Ultrasound
Please bring prior films if outside Total Imaging Centers for comparison evaluation.
Mamografía:
(No
use
desodorante,
polvo,
o
perfume
el
día
del
examen.
Exams:
(No
coma
o
beba
nada
desde
las
12
pm
hasta
que
el
examen
este
use the bathroom. Your bladder must remain full for the exam.
examen siguiendo cuidadosamente las instrucciones.
Estos examenes
Por favor traiga sus placas para comparar.
completo.)
Ultrasonido de la Vesicula: (Beba 1 quarto de liquido una hora antes del requieren instrucciones especiales. El prep kit esta disponible por medio de
examen y NO use el bano. Debe mantener la vesicula llena para el examen.) su medico o por los consultorios de Tower/Total Diagnostic Centers.)
Mammograms: Do NOT use deodorant, powders, or perfume on day
of exam. Please bring prior films if outside Total Imaging Centers for
comparison evaluation.
Mamografía: (No use desodorante, polvo, o perfume el día del examen.
Por favor traiga sus placas para comparar.
Upper GI (UGI) Series, Gallbladder, Liver, Pancreas Ultrasound
Exams: Do NOT eat or drink anything from midnight the night before your
exam until the exam is complete.
Upper GI (UGI) Series, Gallbladder, Liver, Pancreas Ultrasound
Exams: (No coma o beba nada desde las 12 pm hasta que el examen este
completo.)

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