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Patient Last Name: 
Patient First Name:
Patient Room Number or Address:
Date of Birth:
Social Security Number:
Ordering Physician/Practitioner:
Name of Person Ordering Exam:
Contact Phone # for Person Ordering:
Contact Phone Number for Patient: 
(for Private/In-Home Patients Only)
Fax # Where Results Should be sent: 
Diagnoses/Symptoms/Reason for Exam:
Reason Exam Needs to Be Perfomed Portably:
Is Patient in a Locked Memory Care Unit?:   
Additonal Comments:
  X-RAY EXAMS (Check All That Apply)
ULTRASOUND EXAMS (Check All That Apply)
     CHEST           LOWER EXTREMITIES      Venous Doppler Upper Extremity     
 Iliac Duplex   -   93978
     - 76856
 LS Spine - 3 Views - 72100    
     Extremity Soft Tissue Ultrasound - 76881
     EKG       - 76536
  Other Exam Not Listed:    
 Hippa Compliant Document Upload 

Please Upload All Relevant Documents  - You can also fax documents to 888-493-1890

Documentation Needed for All Patients: 

1. Physician/Nurse Practitioner Medical Order* 
 2. Facesheet or Insurance Card

Additional Documentation Required for Patients with Medicare:
 3. Related Clinical Notes / Soap Note
 4. History & Physical (if applicable)
Physician's Electronic Signature: I certify that the patient requires portable x-ray services due to existing physical and/or mental conditions that limit their mobility and ability to obtain an exam of their own accord. It would be physically and mentally taxing for the patient to leave their room or home to obtain this exam and they would require assistance in order to do so.         
Physician / ARNP Name:   Title:   Date:  

Please sign with Mouse or Finger if Possible: 

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