After Submitting this Order You Must Call to Schedule
(386) 239-8270 | (877) 717-2010

When you call please provide the order number: 00
PRIORITY: STAT    ASAP    TODAY    FUTURE DATE DATE EXAM NEEDED:
TODAY'S DATE:
FACILITY:
WING:
PHONE:
FAX:
PATIENT NAME:
DOB:
AGE:
ROOM# / BED:
 
Type of Exam:    XRAY     XRAY W/DISK     EKG      ECHO      ULTRASOUND/DOPPLER
 
PLEASE NOTE: THIS IS NOT A PHYSICIAN'S ORDER, ALL INFORMATION INDICATED ON THIS REQUEST MUST BE ON THE SIGNED PHYSICIAN'S ORDER AND ATTACHED WITH THE PATIENT'S FACE SHEET

SIGNS, SYMPTOMS OR DIAGNOSIS

* MUST BE WRITTEN ON THE DOCTORS ORDER

PORTABLE X-RAY (DIGITAL)

NUMBER of VIEWS
MUST BE WRITTEN ON THE DOCTORS ORDER

ULTRASOUND AND DOPPLER (DIGITAL)

STAT DOPPLERS available on weekends/after-hours
 Abd, distention
 Abdominal mass
 Abdominal pain
 A-Fib
 Aortic stenosis
 Arrhythmia
 Aspiration
 Bowel obstruct
 Bruit
 Cardiomegaly
 Carotid stenosis
 Chest Pain
 CHF
 Claudication
 Congestion
 COPD
 Cough
 DVT
 Diarrhea
 Dizziness
 Edema
 Fever
 Heart murmur
 Hematuria
 Hypertension
 Hypoxia
 Kidney stone
 Nausea
 Pain
 +PPD
 Palpitations
 PAD/PVD
 Pelvic mass
 Pelvic pain
 PICC
 Pneumonia
 PVCs
 Renal failure
 DOB
 Swelling
 Syncope
 Tachycardia
 TIA
 Urinary retention
 Vomiting
 Wheezing
 Other: 
HEAD
 FACIAL BONES   2 VIEWS
 SINUSES   2 VIEWS
 SKULL   2 VIEWS
CHEST
 CHEST AP  R   L   B 1 VIEW
 CHEST AP/LAT   2 VIEWS
 CHEST + RIBS   3 VIEWS
 EKG - 12 LEAD    
 RIBS  R   L   B 2 VIEWS
ABDOMEN
 ADOMEN COMPLETE   2 VIEWS
 KUB   1 VIEWS
SPINE
 CERVICAL SPINE   2 VIEWS
 LUMBAR SPINE   2 VIEWS
 SACRUM/COCCYX   2 VIEWS
 THORACIC SPINE   2 VIEWS
UPPER EXTREMITY
 CLAVICLE  R   L   B 2 VIEWS
 ELBOW  R   L   B 2 VIEWS
 FOREARM  R   L   B 2 VIEWS
 HAND/
    FINGERS
 R   L   B 3 VIEWS
 HUMERUS  R   L   B 2 VIEWS
 SHOULDER  R   L   B 2 VIEWS
 WRIST  R   L   B 3 VIEWS
LOWER EXTREMITY
 ANKLE  R   L   B 3 VIEWS
 CALCANEUS/
     HEEL
 R   L   B 2 VIEWS
 FEMUR  R   L   B 2 VIEWS
 FOOT/TOES  R   L   B 3 VIEWS
 HIP  R   L   B 2 VIEWS
 KNEE  R   L   B 2 VIEWS
 PELVIS  R   L   B 1 VIEWS
 TIBIA-FIB  R   L   B 2 VIEWS
 OTHER: 

PORTABLE XRAY
REQUESTED DUE TO:

* MUST BE WRITTEN ON THE DOCTORS ORDER
 ALTERED MENTAL STATUS
 BED RIDDEN
 DEMENTIA
 GENERALIZED PAIN
 MEMORY LOSS
 MUSCLE WEAKNESS
 SOB UPON EXERTION
 UNSTEADY GAIT
 WHEELCHAIR BOUND
 OTHER: 
 ABDOMEN COMPLETE (NPO 8 HOUR)
 MASS (SOFT TISSUE) LOCATION
 RENAUBLADDER (28 OZ WATER)
 THYROID
 CAROTID DOPPLER
 RENAL ARTERY DOPPLER (NPO 4 HOURS)
 BLADDER - PRE/POST VOID (28 OZ WATER)
 PELVIS (NON OB) (32 OZ WATER)
 TESTICULAR/SCROTUM
     (WITH COLOR FLOW)
 ABDOMEN AORTA (NPO 4-6 HOURS)
 VENOUS DOPPLER/DVT.........................
        UPPER /  LOWER EXTREMITY
        R   L   B
 ARTERIAL DOPPLER WITH ABIS...........
        UPPER /  LOWER EXTREMITY
        R   L   B
 ECHOCARDIOGRAM COMPLETE
 OTHER: 
 
I REQUEST THAT PAYMENT OF AUTHORIZED MEDICARE AND\OR INSURANCE BENEFITS BE MADE ON MY BEHALF TO ATLANTIC MOBILE IMAGING AND\OR THE INTERPRETING PHYSICIAN FOR ANY SERVICES FURNISHED TO ME BY THAT PHYSICIAN OR SUPPLIER. I AUTHORIZE ANY HOLDER OF MEDICAL INFORMATION ABOUT ME TO RELEASE TO THE CENTER FOR MEDICARE AND MEDICAID SERVICE AND ITS AGENT ANY INFORMATION NEEDED TO DETERMINE THESE BENEFITS PAYABLE FOR RELATED SERVICES.
 
 PATIENT’S SIGNATURE

 NURSES CHECK HERE IF PATIENT IS UNABLE TO SIGN

ORDERING PHYSICIAN:
FIRST LAST PHONE
 
Date
 PHYSICIAN'S SIGNATURE REQUIRED
 
Time
 LICENSED NURSE'S SIGNATURE REQUIRED

NURSE'S NAME:
FIRST LAST PHONE

FACE SHEET AND DOCTOR'S ORDERS MUST BE UPLOADED BELOW
OR FAXED TO 386-239-8273

Include Order Number 00 on faxes

 
Upload - DOCTOR'S ORDERS 
Upload - FACE SHEET 
CFA 486. 106 STATES IN PART: "SUCH PHYSICIAN'S WRITTEN SIGNED ORDER SPECIFIES THE REASON AN X-RAY TEST IS REQUIRED. THE AREA OF BODY TO BE EXPOSED, THE NUMBER OF RADIOGRAPHS TO BE OBTAINED AND THE VIEWS NEEDED; IT ALSO INCLUDES A STATEMENT CONCERNING THE CONDITION OF THE PATIENT WHICH INDICATES WHY PORTABLE X-RAY SERVICES ARE NECESSARY."


 

After you click "Submit" you will be able to downloand a PDF copy of this Order