(Please select salutation) Appointment Date/Time: Remove Cast "Electronically Signed" Phone No. Prac. No. Fax No.
Subject: Draw Checkmarks
PROCEDURE:
Modality:
X-ray CT Ultrasound Doppler
Barium Enema ES&D
Routine 18 week Obstetrical US
Dating Obstetrical US
Obstetrical US for GDM
Side:
Left Right Bilateral
Body Part(s):
Head Sinuses Carotids
Chest Abdomen Pelvis
Obstetrical
C-spine T-spine L-spine
Shoulder Humerus Elbow
Forearm Wrist Scaphoid Hand
Hip Femur Knee
Lower leg Ankle Foot Calcaneus
REASON FOR EXAMINATION:
pain swollen decreased ROM
chronic cough GERD Change In Bowel Habits
fall FOOSH trauma
?pneumonia
?fracture ?dislocation ?OA
TEST PROTOCOL:
US ABDOMEN
US RENAL
US PELVIC OR OBSTETRIC
US THYROID/BREAST/SCROTAL
MUCOMYST PRESCRIPTION