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Patient Name: ___________________________________________ DOB: ___________ Appt. Date: __________ Appt. Time: __________ Patient Phone: _________________ Referring Physician: ______________________________ SPECIAL REPORTING INSTRUCTIONS: J E R E M Y N . W I E R S I G M . D . , P. A .
Addl. Referring Physicians: _______________________________________________________ ❑ Films with Report to Office ❑ CD W/ Report 18802 Meisner Drive (OFF E. SONTERRA BLVD)
San Antonio, TX 78258 | TEL 210 572 2222 | FAX 210 249 2177 Diagnosis/Clinical History: ______________________________________________________ ❑ Fax STAT Report: ______________________ 423 Treeline Park, Suite 100 | San Antonio, TX 78209 ______________________________________________________________________________ Call Report: ❑ to Office ________ _________ Follow Up Doctor Appointment Date: _______________ Time: ____________________ Underlined Exams Usually Require Appointments EXAMS REQUIRING SPECIAL PREPARATIONS & MAPS ON BACK Previous Films & Location: ______________________________________________________ P E T C T (Stone Oak Only)
B O N E D E N S I T Y S T U D Y ( D E X A )
❑
❑ Skull Base to Mid-Thigh with CT Fusion* Osteoporosis Scan ❑ Lateral Vertebral Assessment* ❑ Body Composition ❑ Per Radiologist ❑ Intra-articular Gadolinium (Joint) ❑ Whole Body (Melanoma) with CT Fusion* D I G I T A L M A M M O G R A P H Y /
See CT section to order a diagnostic CT study B R E A S T D I A G N O S T I C S
NUCLEAR MEDICINE w/plain films if needed (Stone Oak Only) Where______________________________ When__________________
❑ Gastric Emptying■ ❑ W/ Liquid ❑ W/ Solid ❑ Screening Mammogram (no symptoms) - w/ return work-up ❑ Unilateral Mammogram ❑ LT ❑ RT ❑ Galactography ❑ RBC Liver Hemangioma ❑ Thyroid Uptake & Scan■ S P E C I A L P R O C E D U R E S
❑ Joint Injection_______________ ❑ Biopsy*_______________________ _____________________________ ❑ Myelogram▲ R A D I O G R A P H Y (No Appointment Necessary)
Serum Creatinine____________________________Date_____________ (Required if >50 years or diabetic) U L T R A S O U N D
❑ Right Upper Quadrant■ ❑ Complete OB◆ ❑ Ribs ❑ LT ❑ RT ❑ BIL FLUOROSCOPY ❑ Sinuses (Coronal) ❑ Abdomen/Pelvis▲,* ❑ Kidney (Renal) - Bilat.■ ❑ Fetal Biophysical Profile◆ ❑ Biopsy*___________________ ❑ Cyst Aspiration*_______________ (Required if >50 years or diabetic) ❑ Fine Needle Aspiration*____________________________________ M R / C T A N G I O G R A P H Y
V A S C U L A R U L T R A S O U N D
S P E C I A L I N S T R U C T I O N S / A U T H # :
E X A M P R E P A R A T I O N S
These preparations must be followed completely to ensure accurate test results. For the preparations for other procedures, please call our office.
Nothing to eat, drink, chew or smoke after midnight.
Nothing to eat, drink, chew or smoke 4 hours prior to exam.
Drink 32oz. of water 1 hour prior to exam (DO NOT VOID).
Special preparation required, call our office.
❑ CT SCAN: Please inform the scheduler if you are taking Glucophage, Glucovance, Metformin, Avandamet, or Metaglip. Nothing to eat or drink for 3 to 4 hours prior to exam time, (except for CT sinus). We will be calling you to ask you important questions regarding your medical history. Patients receivingoral contrast may experience diarrhea.
❑ CT SCAN (abdomen): If you have not picked up your oral contrast prior to exam, please arrive 1 hour early to receive the contrast agents for ❑ CT SCAN (abdomen and pelvis): If you have not picked up your oral contrast prior to exam, please arrive 2 1/2 hours early to receive the contrast ❑ MAGNETIC RESONANCE IMAGING (MRI/MRA): We will be calling you to ask you important questions regarding your medical history. *Do not wear jewelry, hairpins, and barrettes for this exam.
FREE CITY-WIDE TRANSPORTATION AVAILABLE FOR PATIENTS UNDERGOING CT, MRI, AND PET EXAMS SAN ANTONIO AREA MAP
NORTH SAN ANTONIO MAP
Visit our website for information about the imaging centers and the procedures. Download and pre-print a registration form and questionaires before your visit.

Source: http://www.concordimaging.com/webdocuments/concord-imaging-exam-request-form.pdf