Phone 410-838-6767 Fax 410-838-7895 Imaging Request
Please bring this form, your insurance card
www.progressiveradiology.net
q PATIENT TO RETURN WITH FILMS CD q PRIORITY: FAX WHEN READ q CALL IN STAT RESULTS, PH#: For CT/MRI Bun/Creatinine within 6 weeks: Creatinine , Lab Date If unavailable, check STAT sensor test q STAT Sensor - on site lab CHECK PROCEDURE(S) REQUESTED 3T MRI (CONTRAST AS INDICATED) CT (CONTRAST AS INDICATED) GENERAL ULTRASOUND VASCULAR ULTRASOUND
q Low Dose Chest (Lung Cancer Screening)
q Arterial Duplex - ABI - Lower Extremity
DIGITAL MAMMOGRAPHY W/CAD
q Diagnostic (with sonography if indicated)
q EXTREMITY:__ Right __ Left __ Bilateral
OB ULTRASOUND
____ Implant integrity (no cancer suspicion)
____ Annual screening per ACS (after mammo)BONE DENSITOMETRY
q Follow up: Growth/Other:_______________
____ Breast Cancer Diagnosis - evaluation
FLUOROSCOPY MR ANGIOGRAPHY PEDIATRIC IMAGING DIGITAL XRAY ARTHROGRAPHY PATIENT INSTRUCTIONS Please arrive at the center 15 minutes prior to your exam
All Studies: No jewelry, hair accessories, make-up or hair spray. Please inform us of the presence of the following: pacemaker, ear implants, implanted device for pain control, aneurism clips, metal in the body, worked with metal in the past, or if you are pregnant. • ARTHROGRAMS • CAT SCAN With Contrast (a.m. appointment): Nothing to eat or drink after midnight before the exam (p.m. appointment): Nothing to eat or drink 3 hours before the exam Without Contrast: No prep required. • ULTRASOUND Abdomen (a.m. appointment): Nothing to eat or drink after midnight before the exam (p.m. appointment): Liquid breakfast allowed; no food or drink before the exam Pelvis: Drink 32 oz water 1 hour prior to exam. Do NOT empty bladder. Renal US and/or Pregnancy US: Drink 16 oz water 1 hour prior to exam. Do NOT empty bladder. • UGI and/or SMALL BOWEL FOLLOW THROUGH
Nothing to eat or drink after midnight before the exam
On the day prior to the procedure, eat a normal breakfast, then only clear liquids for the rest of the day. Dulcolax laxative (2 tabs) at 6 p.m., then nothing to eat or drink after midnight.
No preparation required. We recommend that parents bring a pacifier and/or bottle for child. PROGRESSIVE RADIOLOGY AT THE COLONNADE 100 Fulford Avenue Bel Air, MD 21014 Phone 410-838-6767 Fax 410-838-7895 www.progressiveradiology.net Directions: From Rt. 924/24 North (Bel Air / Forest Hill Area) Follow Route 924/24 into Bel Air straight through traffic light at Broadway (ShopRite store on left). The street name will change to N. Bond Street. At the fourth light on N. Bond Street, make a left onto Baltimore Pike (Route 1). At first traffic light, the sign will say “Main Street.” Go straight through the light and immediately get in the left lane. The Colonnade is in the first block on your left. It is a long brick building with columns in the front. From Rt. 924 South (Abingdon / Edgewood Area) Follow Route 924 (Emmorton Road) into Bel Air. After you pass Friendly’s Restaurant on the right, make a right at the first traffic light onto Fulford Road. Immediately get in the left lane. The Colonnade is in the first block on your left. It is a long brick building with columns in the front. From Rt. 22 North (Havre de Grace / Aberdeen Area) Follow Route 22 (Churchville Road) south into Bel Air. After passing the John Carroll School on the left, the road will widen and become one-way. Stay in the left lane. At the first light make a left on Maitland Street, then make an immediate right into our parking lot. Follow the parking lot around to the left, then you will be in front of the Colonnade. It is a long building with columns in the front. From Rt. 24 South (Abingdon / Edgewood Area) Follow Route 24 (Vietnam Vets Memorial Highway) into Bel Air. Make a right onto Baltimore Pike (Route 1). After crossing over Main Street, the street name changes to Fulford Avenue. Immediately get in the left lane. The Colonnade is in the first block on your left. It is a long building with columns in the front.
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Phone 410-838-6767 Fax 410-838-7895
PATIENT INSTRUCTIONS