MRI CT

Fax Scheduling
843.747.6565
TRICOUNTY RADIOLOGY ASSOCIATES
 Call patient
to schedule
Moncks Corner │ North Charleston │West Ashley
Tax ID #: 56-2231622
Ph: 843.529.0600 www.scdiag.com
(See reverse side for address & directions)
Patient Name:_________________________________________________________________ DOB:______________________________
Appointment Date:________/_________/____________ Arrival Time:__________am / pm Appointment Time:___________am / pm
Phone Number: Mobile:_____________________________________
MRI
Contrast:  Rad Discretion
 with  without  with & w/o
 Brain
 IAC w/wo
 Pituitary
 Orbits w/wo
 Seizure Protocol
 Cervical Spine
 Thoracic Spine
 Lumbar Spine
 Soft Tissue Neck
 MRA of:___________
 Stroke Protocol
(Brain, MRA Head, MRA Neck)
 Abdomen
Rt Lt Bilat
Shoulder
Rt Lt Bilat
Elbow
Rt Lt Bilat
Wrist
Rt Lt Bilat
Hip
Rt Lt Bilat
Knee
Rt Lt Bilat
Ankle
Rt Lt Bilat
Foot
 Forefoot  Hindfoot
 MR Arthrogram Rt Lt
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






 Other___________________
________________________
CT
Other:_______________________________________
Ultrasound
Contrast:  Rad Discretion
 with  without  with & w/o
 Abdomen
 Gallbladder (Right Upper Quadrant)
 Renal (Kidneys & Bladder)
 Brain
 Pelvic (Transvaginal as indicated)
 Orbits
 Carotid Doppler
 Paranasal Sinus
 Venous Doppler
 Paranasal Sinus Stereotactic
 RUE  LUE  RLE  LLE
 Stealth/Brain Lab
 Duplex Aorta, IVC, Iliac Vas, or
 Fusion
Bypass Grafts
 Temporal Bones/IAC
 Limited
 Facial Bones
 Complete
 Abdomen & Pelvis
 Follow-up
 Stone Protocol
 OB
 Abdomen (only)
 Thyroid
 Scrotum - with Doppler
 Pelvis (only)
Chest
Soft Tissue Neck
C-Spine
L-Spine
T-Spine
CTA (all w & w/o)
 Abdomen  Pelvis
 Head
 Aorta
 Neck
(Run-off)
 Dedicated Studies (all w & w/o)
 Adrenal  Pancreas
 Liver
 Renal






Advanced Imaging
 3D Reconstruction
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Comments
______________________
______________________
 Other:_____________________
______________________
__________________________
______________________
__________________________
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Fluoroscopy
 IVP
 IVP with Tomography
 Barium Swallow
 Upper GI (includes limited esophagram)
 Small Bowel Follow Through
 Other:_________________
 Cardiac Score
X-ray
Please specify:
Bone Densitometry
 Bone Mineral Densitometry (DEXA)
______________________
______________________
______________________
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Report Delivery
 Within 24 hours
 STAT Fax
Fax#_______________
 Call Report
Cell or Backline #:
___________________
Clinical Indications/Signs/Symptoms: ______________________________________________________________________________
Physician Name (Printed)________________________________________ Physician Signature_________________________________
RP-SC-TRI_Rev. 01/2015
TRICOUNTY RADIOLOGY ASSOCIATES
Moncks Corner │ North Charleston │West Ashley
Visit our website www.scdiag.com to see pictures of our equipment and view maps.
MRI (Magnetic Resonance Imaging)
Please have patient contact our office 24 hours before appointment for prep instructions.
Do not wear any eye make-up for ALL Head & Neck studies.
CT (Computed Tomography)
Please have patient contact our office 24 hours before appointment for prep instructions.
Fluoroscopy
by mouth after midnight
..Nothing
UGI
(Barium Swallow)
. Esophogram
Small Bowel Follow Through
.
Pick up prep kit from one of our offices
IVP (Nothing by mouth 2 hours prior to exam)
Ultrasound
..
.
Bladder
..FullPelvic
OB or Non OB:
32-40 oz of water (4-5 [8oz] glasses)
. 1 hour before exam
Nothing by mouth after midnight
Abdominal
Gallbladder
Renal (also see Full Bladder prep)
..
..
No special prep
Thyroid
Scrotum
Carotid
Venous
52
Berkely
Baptist
Church
52
. S8- 5
0
i c al P
l a za D
ri
Health
South
Hospital
Tricom St.
Edenbrook
Trident
Hospital
ve
ed
M
Silk Oak Dr.
Berkely Co.
Water &
Sanitation
S .R
Dunkin
Donuts
I-26 E
Berkeley
Family
Practice
Charleston Southern
University
Towards
Towards
S’ville
Hwy 78
Rivers Ave.
Home
Depot
Magwood Drive
I-26W
Our Locations
Hw
y. 6
526
1
(Next to Kohl’s)
Chick-Fil-A
Paul Cantrell Blvd.
St. Francis
Hospital
 Moncks Corner
2061 Hwy 52 S, Suite 400
Moncks Corner, SC 29461
(located inside
Berkeley Family Practice)
 North Charleston
2851 Tricom St.
N. Charleston, SC 29406
 West Ashley
1975-H Magwood Rd.
Charleston, SC 29414
Hw
y. 6
1
Mark Clark
7
Hwy. nberg
itte
Sam R