CRL Referral Form

Requested Date:

MonthDayYear
Requested Time:

Hour Minutes

AM/PM Option
Location:*

CRL Imaging Southdale/Women's Imaging
Scheduling/Special Instructions:*

CRL to call patient to scheduleCRL to call referring office to scheduleRead and call reportCRL to send copy of images with patientOther
Patient Information
Patient Name:*

FirstLast
Date of Birth:*

MonthDayYear
Home Phone:*
Work or Cell Phone:*
Clinical History
Diagnosis:*
Known Allergies:*
Patient Insurance
Insurance Company:
Policy #
Group #
Check if applicable

Personal Injury / Auto InjuryWorkers Compensation
Personal Injury / Auto Injury Details
Claim #
Phone
Date of Injury

MonthDayYear
Workers Compensation Information
Employer
Adjuster's Name
Claim #
Insurance Company
Phone
Physician Information
Name of Referring Physician*
Clinic Name*
Office Phone*
Office Fax
Exam Information
Exam Type and Location*

FNAX-RayUltrasoundMammography/Breast ImagingBone Density (DXA)
X-Ray*

Cervical AP, Lat & Open Mouth (3 view)Cervical- 3 View, w/ Flexion & Ext.Davis Series (7 Cervical Views)Thoracic AP & Lateral (2 Views)Thoracic — 2 View w/ Swimmers ViewLumbar AP & Lat w/ Lat L5-S1 Spot (3 View)Lumbar — 3 View w/ AP PelvisLumbar — 3 View w/ ObliquesLumbar — 3 View w/ Flexion & ExtOther - Please Specify
Please select an area

BodyExtremitiesHead & NeckSpineOther - Please Specify
Ultrasound*

AbdomenRenalPelvicVenousScrotumLiverThyroidAortaParacentesisCarotidOBOther - Please Specify
Abdomen*

CompleteLimited
Renal*

w/DopplerBladder
Pelvic*

w/DopplerFollicle
Venuous*

RightLeft
Scrotum*

w/Doppler
Liver*

w/Doppler
Thyroid*

FNA
Aorta*

ABI
Ultrasound - Paracentesis*

TherapeuticDiagnosticBoth
OB*

BiophysicalMeasurements < 14 Weeks> 14 Weeks
Mammography/Breast Imaging*

MammogramUpright Stereotactic BiopsyUltrasound Guided Breast BiopsyBreast UltrasoundUltrasound Guided Cyst Aspiration
Type*

Screening (Asymptomatic)DiagnosticFull Diagnostic
Which technology do you prefer?*

2D (Digital) Mammography3D Mammography (Tomosynthesis)Patient Preference
Area of Concern:

Left BreastRight BreastBilateralOther - Please Specify
Should be Empty:

Patient Information

Clinical History

Patient Insurance

Personal Injury / Auto Injury Details

Workers Compensation Information

Physician Information

Exam Information