Imaging Order

Imaging Order / Patient Referral
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Sex*

MaleFemale
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Email*
Will be used to notify patient of study order.
Ordering Physician*
NPI Number*
Facility / Practice Name*
Office Phone*
Fax Number*
Please enter a valid phone number.
Point of Contact in Office*
Payment Option*

Self-PayBill Insurance
Primary Insurance*
Insurance ID#*
Group #*
Primary Subscriber Name*
Primary Subscriber DOB*

MonthDayYear
Date
Please Upload Patient Insurance Card

Cancelof
Order(s) Requested*
Associated Diagnosis Codes (ICD-10)*
Please select contrast needs (if not specified above)

Per Radiologist ProtocolWithoutWith & WithoutWith Only (Rare for MRI Eaxms)
Contrast Clearance

For patients needing contrast, we will need to have eGFR labs ordered and completed within 30 days prior to imaging based on the following:
CT Exam WITH Orders

60 years of age or olderRenal (Kidney) Disease
MRI Exam WITH Orders

Renal (Kidney) Disease
Preliminary MRI Safety Screening (check all that apply)

Pacemaker, pacer wires, or defibrillatorSurgical metals: aneurysm clips, neurostimulator, non-cardiac stents (vascular shunt)Non-surgical metals (fragments in eye, shrapnel, piercings)Blood infusions for iron deficiency in the past 3 months
Exam Comments / Reason for Exam
Surgical history of area being imaged:
Physician Signature*

Clear
Additional Documents (optional)

If you have any additional documentation that you think will be helpful, please attach them here.
Cancelof
Additional Comments (optional)
In order to prevent fraudulent submissions, we ask that referrers please provide an access code to use this form. If you do not know the access code, please call our office and we will provide it for you: 616-980-9050. Thank you for understanding!
Access Code*
Should be Empty:

Imaging Order / Patient Referral

Contrast Clearance