Radiology Department CT Order Form Order Date: Ordering Physician Diagnosis/Symptoms: Patient Name Appt Date D.O.B. Appt Time Precert Number LAB BUN CREATINE ** For all contrast studies, please have BUN & Creatine labs drawn 24-48 hrs prior to radiology exam** STUDY DECRIPTION CT Abdomen & Pelvis WO Contrast CT Abdomen & Pelvis W Contrast CT Abdomen & Pelvis W/WO Contrast CT Abdomen WO Contrast CT Abdomen W Contrast CT Abdomen W/WO Contrast CT Cervical Spine WO Contrast CT Cervical Spine W Contrast CT Cervical Spine W/WO Contrast CT Chest Thorax WO Contrast CT Chest Thorax W Contrast CT Chest Thorax W/WO Contrast CT Head WO Contrast CT Head W Contrast CT Head W/WO Contrast CT Lower Extremity WO Contrast L CT Lower Extremity WO ContrastR CT Lower Extremity W Contrast L CT Lower Extremity W Contrast R CT Lower Extremity W/WO Contrast L CT Lower Extremity W/WO Contrast R CT Lumbar Spine WO Contrast CPT STUDY DECRIPTION 74176 74177 74178 74150 74160 74170 72125 72126 72127 71250 71260 71270 70450 70460 70470 73700LT 73700RT 73701LT 73710RT 73702LT 73702RT 72131 CT Max Facial WO Contrast CT Max Facial W Contrast CT Max Facial W/WO Contrast CT Orbital WO Contrast CT Orbital W Contrast CT Orbital W/WO Contrast CT Pelvis WO Contrast CT Pelvis W Contrast CT Pelvis W/WO Contrast CT Soft Tissue Neck WO Contrast CT Soft Tissue Neck W Contrast CT Soft Tissue Neck W/WO Contrast CT Thoracic Spine WO Contrast CT Thoracic Spine W Contrast CT Thoracic Spine W/WO Contrast CT Upper Extremity WO Contrast L CT Upper Extremity WO Contrast R CT Upper Extremity W Contrast L CT Upper Extremity W Contrast R CT Upper Extremity W/WO Contrast L CT Upper Extremity W/WO Contrast L CT Lumbar Spine W Contrast 72132 CT Lumbar Spine W/WO Contrast 72133 Physician Signature Emanuel Medical Center 117 Kite Road Swainsboro, GA 30401 Office Number (478) 289-1285 Fax Number (478) 289-1289 CPT 70486 70487 70488 70480 70481 70482 72192 72193 72194 70490 70491 70492 72128 72129 72130 73200LT 73200RT 73201LT 73201RT 73202LT 73202RT
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