General Order Form

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Group *

Your Email Address

Fax

Completed By *

Date Needed By

Insurance Provider *

Insurance ID

Pre-Auth / Referral # *

Follow-up Appt. Scheduled On

Effective Date Range Starts

Effective Date Range Ends

Patient Name *

First

Last

Date of Birth (mm/dd/yyyy) *

Patient Sex

Male
Female

Home Phone *

Preferred Contact #

Electronically Signed By (clinician) *

Credentials

Signature Date

Send additional reports to

General Exam Information

Exam(s) Requested

Biopsy
CT
DEXA with TBS
Fluoroscopy/Diagnostic
Mammography
Automated Breast Ultrasound (ABUS)
MRI
Ultrasound
X-ray
PET/CT

Ordering provider cell#

Exam Location(s)

Biopsy Type

Stereo/Mammography
Ultrasound

Biopsy Location

RiverBend Pavilion
University District

Pet/CT Location

RiverBend Pavilion Only

Biopsy Location

RiverBend Pavilion Only

CT Location

University District Only

DEXA Location

University District Only

Fluoroscopy/Diagnostic Location

University District Only

X-ray Location

University District Only

Mammography Location *

RiverBend Pavilion
University District

ABUS Location *

RiverBend Pavilion ONLY

Ultrasound Location *

RiverBend Pavilion
University District

MRI Location *

RiverBend Pavilion
University District

CT Information

MRI Information

IV Contrast

Without Contrast.
With Contrast.
With & Without Contrast.
At Radiologist's Discretion.
Shared Decision Making Visit.

Notes

Please note: MR exams are rarely performed as a "with contrast" only.

Please Note: If your patient is claustrophobic, it is the referring clinician's responsibility to provide any prescription for the patient to take prior to their MRI exam.

If any of these questions are answered "yes" and the MR exam will require IV contrast, lab values for BUN, Creatinine and GFR within 6 weeks of exam are required.

1. Is the patient 60 or more years of age?
2. Does the patient have diabetes requiring medication?
3. Hypertension requiring medication?
4. Single/solitary kidney?
5. History of renal disease (i.e. renal tumor, failure, acute injury or transplant)?
6. Hepatorenal syndrome related to a liver transplant?

If the answer is "yes" to any of the questions below, and the CT exam will require IV contrast, then lab values for Creatinine and GFR are required within 6 weeks of the scheduled exam. New labs are also required if a CT iodinated IV contrast study was performed within 48 hrs of a new CT iodinated contrast imaging study.
Note: Patient on dialysis should have dialysis within 24 hours after IV Contrast.

1. Kidney disease? (including single kidney, failure, transplant, renal cancer or renal surgery)?
2. Diabetic?

Recent Lab Values

Requested Date / Time

Creatinine

Blood Urean Nitrogen (BUN)

Glomerular Filtration Rate (GFR)

Notes

Special CT Information

Iodine Allregy

Iodine Allergy Reaction

If patient is having an IV contrast CT exam and reports an allergy to Iodine please contact Oregon Imaging Centers at 541-334-7555 for review of reaction and determination of premedication prep if indicated.

Mammography Information

Please note: screening mammograms (no breast symptoms). OIC recommends diagnostic mammography for patients with new breast symptoms and/or personal history of breast cancer diagnosed within the last 4 years.

ABUS Information

Please note: OIC recommends ABUS in addition to diagnostic mammography for patients with dense breast tissue and/or a strong family history of breast cancer. ABUS is available ONLY at the RiverBend Pavilion Location.

Ultrasound Information

Pet/CT Information

Important Note

Radiologist may determine workup to include additional imaging if needed. (Including ABUS)
Call my office prior to doing additional studies. (Including ABUS)

Important Note

Radiologist may determine workup to include additional imaging if needed.
Call my office prior to doing additional studies.

Important Note

Radiologist may determine workup to include additional imaging if needed.
Limited Doppler per Radiologist Protocol.
Call my office prior to doing additional studies.

To order a PET/CT exam, please fax a completed PET/CT order form to 541-334-7556. Download the form here. All PET/CT services, including oncologic and neurologic studies, are offered at our RiverBend Pavilion clinic.

Examination / Area(s) of Special Interest *

Signs & Symptoms / Clinical Indications / ICD Code *

*As an outpatient only facility we do not perform true STAT exams, if the need is emergent please consider referring patient to an Emergency Department or Urgent Care facility

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