(WRMG) West Rad Medical Group

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N o t e : A l l H M O a u t h o r i z a t i o n s a r e s i t e s pecific.
#954651287
#330285170
 Anaheim Advanced Imaging (BR)
 Orange Advanced Imaging (BR)
 Anaheim X-Ray West (BR)
 Orange Imaging Center (BR)
 La Mirada Imaging (BR)
P: (714) 288-5400 | F:(714) 532-3738
 Santa Ana / Tustin (WRMG)
 Santa Ana / South Coast (WRMG)
P: (714) 835-6055 | F: (714) 285-9084
 Irvine (WRMG)

P: (949) 753-0900 | F: (949) 753-1719
Laguna Niguel/Mission Viejo (WRMG)
P: (949) 272-2200 | F: (949) 272-2210
(BR)
Beverly Radiology|TAX ID#: 954651287
(WRMG)
West Rad Medical Group|TAX ID#: 330285170
Appointment Date:______________________________ Appointment Time:_____________________ Today’s Date:___________________
Patient’s Name:_________________________________________________ Date of Birth:______________________ M or F (circle one)
Patient’s Phone:________________________________________ Alternate/ Cell Phone:_________________________________________
Clinical History/Reason for Exam:______________________________________________________________________________________
_________________________________________________________________________________________________________________
Referring Physician:____________________________________________ Physician Signature:____________________________________
Phone:___________________________ Fax:__________________________  Patient to bring images to Doctor
 Wet Read
Labs needed for Contrast Studies if any of following are marked:
__ Diabetes
__ Renal Disease
Creatinine / GFR _________/_________ Lab date (within 1 month): ___________
MRI
CT
Ultrasound
PET/CT
MRI
 Contrast as indicated
 3D Rendering as indicated
 Brain
 w/special attention to IAC
 w/special attention to Pituitary
 Neuroquant
 Orbits
 TMJ
 Neck - Soft Tissue
 Spine:
 Cervical  Thoracic Lumbar
 Extremity: Joint Left Right
Specify body part_____________
 Extremity: Non-Joint__Left __Right
Specify Body Part_____________
 Breast w/CAD:
 Contrast Tumor Study
 Implant Evaluation
 Chest
 Abdomen
 Abdomen (MRCP)
 Pelvis
 Prostate
 Other:______________________
MR Angiography
 Contrast as indicated
 Brain
 Neck - Carotids
 Chest
 Abdomen
 Aorta  Renal
 Aorta and runoff vessels
 Pelvis
 Extremity: Left Right
 Other:______________________
MR Arthrography  Left Right
 Shoulder
 Elbow
 Wrist
 Hip
 Knee
 Ankle
Diagnostic CT
 Contrast as indicated
 3D Rendering as indicated
 Brain
 Orbits
 IAC Middle Ear  Mastoids
 Maxillofacial - Facial Bones
 Sinus (Maxillofacial)
 Neck (Soft Tissue)
 Spine:
Cer vical Thoracic Lumbar
 Extremity __Left __Right
Specify Body Part_____________
 Chest Nodule Hi-Res
 Abdomen (Pelvis if Indicated)
 Abdomen and Pelvis
 Urogram (Abdomen/Pelvis)
 Pelvis
 Other:______________________
 Abdomen__________
 Abdomen Limited____________
__Liver __Gallbladder
__Upper Right Quadrant
 Abdomen w/Doppler if indicated
 Renal__________
__w/Bladder
 Bladder (w/pre and post voiding)
 Aorta/Retroperitoneal________
 Pelvis (TV if indicated)
 Hysterosonogram
 Scrotum ___w/Doppler
 Thyroid_________
 Venous Doppler (Duplex)______
 Carotid Doppler (Duplex)_____
 Arterial Doppler (Duplex)_____
 ABI
 Segmental Pressures if indicated
 Echocardiogram
 Other_____________________
OB Ultrasound
 OB Ultrasound (TV if indicated)_
 Limited (Viability, Heart Beat,
Position, Fluid, Placental
Location)_____________________
 Follow-up -- specify documented
problem_____________________
 NaF Bone
 PET/CT, Skull Base to Mid-Thigh
 PET/CT, Whole Body (Melanoma)
 PET/CT, Brain
 PET/CT, Brain Amyloid
DEXA
 Bone Density
Reason for bone density:________
____________________________
Date of last exam:_____________
CTA (angiography)
 Head
 Neck
 Extremity: Upper Lower
 Chest
 Aorta and runoff vessels
 Abdomen
 Pelvis
 Cardiac
Coronary Calcium Score
EP Plan
 Other ______________________
Fluoroscopy
 Arthrography
Specify Body Part____________
 VCUG
 Cystogram
 Retrograde Urethrogram
 Esophagram
 Hysterosalpingogram (HSG)
 UGI
 UGI w/SBFT
 Small Bowel
 Lower GI (w/air when indicated)
 Other:____________________
Scheduling Hours: Monday - Friday: 8am - 5pm
For Directions and site information see back of this form*
 Other _____________________
Pediatric Ultrasound
(including but not limited to:)
 Infant Hips Ultrasound
(<1yr of age)
 Neonatal Head Ultrasound
(<1 yr of age)
 Spine Ultrasound
(<6 months of age)
 Pyloric Ultrasound
 Testicular Ultrasound
 Renal w/ Bladder
 Abdomen Complete
 Abdomen (RUQ)
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Nuclear Medicine
 Bone Scan:
__Whole body__Limited __3-phase
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Bone SPECT
Thyroid Scan
Thyroid Uptake and Scan
Parathyroid
MUGA (Cardiac Blood Pool)
Liver or Liver/Spleen
Gallbladder (HIDA) with CCK
Gallbladder without CCK
GI Emptying
GI Bleed
Meckels
Renal __Captopril __Lasix
Gallium
White Blood Cell (WBC)
Other_____________________
X-Ray
 Head:
__Skull __Orbits __Sinuses
 Spine:
__Cervical __Thoracic __Lumbar
 Chest: __PA ____PA/LAT
 Ribs:
__Unilateral__Bilateral __w/PA Chest
 Abdomen: __KUB __Two Views
 Pelvis
 Hips w/AP pelvis, bilateral
__Unilateral __L __R
 Extremity:
__Left __Right __Bilateral
Specify Body Part______________
 Limited Complete
Procedures
 Epidural Steroid Injection
 Facet Block
 Nerve Root Block
Please Indicate what level
_____________________________
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