Download form - Consultants In Diagnostic Imaging, Inc

Consultants in Diagnostic Imaging, Inc.
Mailing Address: 2295 Towne Lake Pkwy. #116-275, Woodstock GA 30189
Phone: 770.575.4196 Fax: 678.279.9944
CDI ACCT #:
CDI DOS:
PATIENT INFORMATION
Patient Name: Date of Birth: M: F: Date of Study: Name of Referring Doctor: PATIENT HISTORY PRESENT COMPLAINT: PERTINENT PAST HISTORY: SURGERY (incl. type and result): SPECIFIC CONCERN: BILLING INFORMATION Bill credit card on file: X‐ray, Cervical spine X‐ray, Thoracic spine X‐ray, Lumbar spine X‐ray, Shoulder X‐ray, Elbow X‐ray, Forearm X‐ray, Wrist X‐ray, Hand X‐ray, Finger X‐ray, Pelvis X‐ray, Iliofemoral (hip) X‐ray, Femur X‐ray, Knee X‐ray, Leg X‐ray, Ankle X‐ray, Heel X‐ray, Foot X‐ray, Toe R R R R R R L L L L L L R R R R R R R R L L L L L L L L MRI. Cervical spine MRI, Thoracic spine MRI, Lumbar spine MRI, Brain/Head MRI, Upper Extremity SH EL MRI, Lower Extremity HIP KN CT, Cervical spine CT, Thoracic spine CT, Lumbar spine CT, Abd/Pelvis CT, Chest CT, Brain CT, Head/Neck CT, Extremity SH HIP US, Cervical Spine US, Lumbar Spine US, SI‐joints US, Extremity SH HIP Jan Martensen, D.C., Ph.D., D.A.C.B.R. Board Certified Chiropractic Radiologist, Director WR LEG HAND ANK FT EL KN WR/HA ANK/FT EL KN WR/HA ANK/FT

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