Columbia-Presbyterian Eastside Radiology
16 East 60th Street
New York, New York 10022
(212) 326-5552 FAX: (212) 326-5555
TIN #: 13-3908644


SCHEDULING:

Patient's Name UNIT #

Clinical Information


Pre-Certification #

Please fax any special instructions to 212-326-5555
MRI CONTRAST: WITH & WITHOUT WITH WITHOUT
Brain Neck C-Spine Wrist MRI Other MRA
Pituitary Breast T-Spine Shoulder Brain
Orbits Abdomen L-Spine Hip Neck
Sinuses Pelvis TMJ's Knee Aorta/Extremity
IAC's Prostate Cardiac Ankle Other
CONTRAST: WITH & WITHOUT WITH WITHOUT
Brain Neck CT Angiogram C-Spine
Pituitary Chest CT Myelogram T-Spine
Orbits Abdomen Lung Screening L-Spine
Sinuses Pelvis Coronary Artery Scoring
Temporal Bones Shoulder Dentascan Other
ULTRASOUND
Abdomen Lower Extremity Venous Doppler Pelvic complete
Kidney Thyroid (includes transvaginal)
Bladder Obstetrical Transvaginal only
Breast Testicular/Scrotal Pelvic - Without transvaginal
Carotid Duplex Hysterosonography Other
BONE DENSITY X-RAY & FLUOROSCOPY
Complete assessment (DEXA & compression fracture assessment) Please indicate procedure
Only DEXA
MAMMOGRAPHY
Bilat Screening: Routine; no problem
Unilat: R L Diagnostic: For example, lump, focal pain, fibrocystic, cancer
Ultrasound if indicated due to mammogram


Requested by

Dr Phone


Appointment Day Time


Films Requested Yes No Film or CD to (address)

CD Requested Yes No

Fax Report Yes No Fax #


PREPARATION FOR DIAGNOSTIC EXAMINATIONS

(WHEN MAKING YOUR APPOINTMENT, PLEASE INFORM THE OFFICE
IF YOU ARE PREGNANT AND CONSULT YOUR PRIMARY PHYSICIAN)

MAGNETIC RESONANCE IMAGING (MRI): MAMMOGRAM:
1. You cannot have an MRI if you have a CARDIAC PACEMAKER or BRAIN ANEURYSM CLIPS or STAPLES (Middle Ear) PROSTHESIS. Do not wear deodorant, powder or lotion on the breast or underarm area. It is important to obtain old mammograms performed elsewhere (originals, not copies) for comparison at the time of your exam. Your doctor or insurance company can tell you where prior exams were performed if you cannot remember.
2. DO NOT WEAR EYE MAKE-UP. G.l. SERIES AND/OR SMALL BOWEL:
3. YOU WILL HAVE TO REMOVE JEWELRY, HAIR PINS AND OTHER METALLIC ACCESSORIES FOR THE EXAM. Nothing to eat, drink or chew 12 hours prior to the exam.
CAT SCAN OF HEAD OR BODY WITH CONTRAST: BARIUM ENEMA WITH/WITHOUT AIR:
Nothing to eat, drink or chew 3 hours prior to exam. 2 Days Before: Follow directions for the 48 Hour Preparation in FLEET BARIUM ENEMA KIT #2. This kit is available in our office at no charge to the patient, or at a pharmacy for a nominal fee.
CT MYELOGRAM:
Nothing to eat or drink 4 hours prior to exam.
ULTRASOUND:
ABDOMINAL: IVP:
Nothing to eat, drink or chew 12 hours prior to exam. Nothing to eat or drink after midnight*.
PELVIC:
1. 1 1/2 hours before appointment, empty bladder.You should not urinate again until after the exam.

* Medications may be taken with a small amount of water.
2. Drink three 8oz. glasses of water and be finished drinking 1 hour before the appointment.
3. See receptionist if you feel you must urinate prior to the exam.


IF A PATIENT HAS DIABETES OR OTHER MEDICAL CONDITION WHICH PREVENTS FOLLOWING A PREPARATION, HE/SHE SHOULD CONSULT HIS/HER OWN DOCTOR.

To order more referral forms,
please call: Columbia-Presbyterian Eastside Radiology
(212) 326-5623

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