� Brain � DTI = Diffusion Tensor Imaging � SWI = Susceptibility Weighted Imaging� Orbits� Brain w/Orbits � IAC’s� TMJ� Pituitary � Soft Tissue Neck � Chest � Brachial Plexus � Cervical Spine� Thoracic Spine � Lumbar Spine� Breast - Bilateral Diagnostic W & W/O CONTRAST� Breast - Implant (Rupture) W/O CONTRAST� Abdomen� Abdomen w/ & w/o contrast - Adrenal Protocol � MRCP� Renals� Urography-Abdomen & Pelvis� Pelvis - Prostate w/ & w/o - 3D MPR As Needed

� Pelvis w/ & w/o contrast - Uterine Fibroid � Pelvis - Routine� Pelvis - Dynamic� Pelvis w/o contrast - Fetal � Shoulder R / L � Arthrogram� Elbow R / L � Arthrogram� Wrist R / L � Arthrogram� Hand R / L� Hip R / L � Arthrogram� Femur R / L� Tib/Fib R / L� Knee R / L � Arthrogram� Ankle R / L � Arthrogram� Foot R / L� Liver w/ & w/o contrast � ONLY Check here for EOVIST Contrast if pt has one of the following indications:

Hepatoma or Cirrhosis or Focal NodularHyperplasia

�W/O CONTRAST�W & W/O CONTRAST

PROVIDE CREATININE ON CONTRAST EXAMS

� Pre-Op Chest X-ray / EKG� Hysterosalpingogram � EKG� Routine Stress Test (Non Pharmacological - Non Thallium)

� Radiologist to determine guidance method for breast biopsy� Stereotactic Breast Biopsy R / L� Ultrasound Breast Biopsy R / L� MRI Breast Biopsy R / L

� Brain (COW) � Carotids� Chest� Chest PE Protocol � Aorta Thoracic � Abdomen Aorta � Renal Transplant Evaluation� Renal Arteries � Pelvis� Abdomen Aorta w/Runoff � Upper Extremity� Lower Extremity (to include Pelvis)

(All CTA’s include IV contrast)PROVIDE BUN/CREATININE

MRI

� Brain (COW) w/o contrast� Arch w/ Carotid w & w/o contrast� Chest w & w/o contrast� Abdomen w & w/o contrast� Pelvis w & w/o contrast� Renals (w/MRI) w & w/o contrast� MRA Run Off to include Pelvis & Lower Extremity w & w/o contrast

PROVIDE CREATININE LEVEL

� Brain� Temporal Bones / IACS / Mastoids � w/MPR� Facial Bones � w/MPR� Orbits � w/MPR� Sinus Maxillofacial� Sinus Coronal� Soft Tissue Neck � w/MPR� Spine C / T / L� Low Dose Lung Cancer Screening w/o

*Signing order you certify patient participation in shared decision making and smoking cessation.� Chest / Thorax � w/MPR� Abdomen & Pelvis� Abdomen � w/MPR� Pelvis � w/MPR� Enterography Protocol - Abdomen & Pelvis w/ - 3D MPR� Kidney Stone Protocol-Abdomen & Pelvis� Virtual Colonoscopy � Incomplete colonoscopy � Non-colonoscopy candidate � Other / screening� Urography Protocol-Abdomen & Pelvis w/ & w/o-3D MPR� Shoulder R / L� Elbow R / L� Wrist R / L� Hand R / L� Hip R / L� Femur R / L� Tib/Fib R / L� Knee R / L� Ankle R / L� Foot R / L � W/IV CONTRAST � W/O IV CONTRAST � W & W/O IV CONTRAST

� W/ORAL CONTRAST

MPR: Multiplanar ReconstructionPROVIDE BUN/CREATININE ON CONTRAST EXAMS

MR Angiography

CT

CT Angiography

PET/CT Imaging

Nuclear Medicine

� Digital Bilateral Screening w/CAD and Bone Density/DEXA� Digital Bilateral Screening w/CAD� Digital Bilateral Diagnostic

w/ Ultrasound (if medically necessary) � Digital Unilateral Diagnostic R / L

w/ Ultrasound (if medically necessary)3D Tomosynthesis � Yes � NoImplants: � Yes � No� Breast Sonogram R / L� Additional Views

Digital Mammography

Breast Biopsy

� Bone Density� Vertebral Fracture Assessment� Body Composition Analysis

X-Ray

� Other: _____________________________________________________________ Request an appointment online: TowerRadiologyCenters.com/appointmentrequest

Ultrasound

� CD � Film: Deliver with Report � Fax STAT Report:

________________________

� PET/CT (Non-Diagnostic CT)� PET/CT (with Diagnostic CT w & w/o)

Please specify area for Diagnostic CT � ALL OR check all that apply:

�Neck �Chest �Abd �Pelvis� PET / Brain Alzheimer’s Eval (AmyVid)� PET / Brain (FDG) PROVIDE BUN/CREATININE WHEN ORDERING DIAGNOSTIC CT

Myocardial Perfusion / Nuclear Stress Test � with Treadmill � no Treadmill� MUGA� Bone Scan - Whole Body� Bone Scan - 3 Phase � Bone Scan - Spine w/SPECT� Biliary Scan with GBEF� 111 Indium WBC Scan� Liver / Spleen Scan� Thyroid Uptake Scan� 131 I Whole Body Scan� Liver Hemangioma� Renal Scan with FlowRenal Scan with Flow � Lasix washout � Captopril / Vaso � Gastric Emptying Study� Parathyroid scan w/Sestamibi

� Sinus� Sinus/Waters1view � Soft Tissue Neck� Chest (CXR)� Abdominal Series� KUB � Pelvis� Hip � SI Joints� Scoliosis � Sacrum/Coccyx� C Spine� C Spine Complete

w/ Oblique and Flex. and/ or Ext.

� T Spine � L Spine� L Spine Complete

w/Bending Views� Bone Age � TMJ� Knee Complete R/L� Foot Complete R/L� Hand R/L� Shoulder Complete R/L� Ankle Complete R/L� Wrist Complete R/L� Elbow R/L� Tibia Fibula R/L� Extremity/Other:_____________R / L_____________R / L

� Thyroid� Echocardiogram� Breast Sonogram R / L� Abdominal Total (Pancreas, Liver, GB, Kidney, Aorta, IVC, Spleen)Retroperitoneal � Kidney / Bladder � Aorta � GB / Pancreas / Liver (RUQ)� Spleen (Left Upper Quadrant)

� High Field � Extremity Open� Open � Weight-Bearing Open

Special Exams

CT Guided Myelogram Procedures

� CT Guided Cervical Myelogram w/CT-3D MPR� CT Guided Thoracic Myelogram w/CT-3D MPR� CT Guided Lumbar Myelogram w/CT-3D MPR

� Cardiac MRI-Cardiac Radiologist to determine exam parameters for cardiac MRI

MRI Cardiac

� Renal transplant w/doppler� Transvaginal� Pelvic w/transvaginal� Pelvic� OB Transabdominal� OB Transvaginal� Testicular Sono w/doppler� Appendix� Bladder

DEXA

Thyroid Therapy� Thyroid Therapy to include Consult �Hyperthyroidism � Thyroid Cancer

� Venous Doppler History: (Please circle) Swelling, Pain, Redness

Lower Extremity � Bilateral � Unilateral R / L Upper Extremity � Bilateral � Unilateral R / L

Rev. 12/17

Vascular Doppler Ultrasound� Carotid Doppler� Arterial Doppler w/ABI Lower Extremity � Bilateral � Unilateral R / L Upper Extremity � Bilateral � Unilateral R / L� Renal Arterial Doppler� SMA Doppler (Superior Mesenteric Arteries)� Liver Doppler� Doppler Vein Mapping Indication: (Please circle) Venous Insufficiency, Varicose Veins Lower Extremity � Bilateral � Unilateral R / L

Patient Name: _________________________________________________________________________________

DOB: __________________ Appt. Date: ______________ Time: ______________ Phone:__________________

Allergies: � NKA____________________ BUN: ____________________ CREATININE: ____________________

Di agnosis orSigns/Symptoms:1.__________________________________2._______________________________________3.____________________________________

Physician (Print)__________________________________________________ Signature _____________________________________Date_______________

(First) (MI) (Last)

� CD � Film: Deliver with Report

� Fax STAT Report:___________________

Request an appointment online:TowerRadiologyCenters.com/appointmentrequest

Scheduling: (813) 874-3177Fax: (813) 879-1809

This exam is medically necessary for this patient Handwritten signature required – No stamps

TOWER Radiology CenterOldsmar

3870 Tampa Rd.813.369.7827

JOHN

MO

ORE

RD.

PARS

ONS

AVE

.

PARS

ONS

AVE

.

BIG BEND RD.

TOWER Radiology Center - Bloomingdale3350 Bell Shoals Rd.

813.654.4883

HENDERSON BLVD.

E. BRANDON BLVD.

S. K

ING

S AV

E.

W. ROBERTSON ST.

SUN CITY CENTER BLVD.COLLEGE AVE.

5454 56

60

60

39

39

41

41

41

19

92

75

4

4

75

75

275

275

275

580TOLL589

TOLL589

301

301

301

92

574

NORTH

COLUMBIA DR.

BAYSHORE

BLVD.

TOWER Radiology CenterWesley Chapel

2324 Oak Myrtle Lane813.751.0422

Within Cypress Creek Development

92

41

LUMBIA DR.

LU

LUM

UM

UM

UM

TOWER Radiology Center - Vonderburg500 Vonderburg Dr.

West Tower, Suite 111813.654.5400

TOWER Radiology Center - Riverview10689 Big Bend Rd., Suite 102

813.672.0608

TOWER Radiology Center - Robertson 414 W. Robertson St.

813.657.6767

TOWER Radiology Center - Parsons 427 S. Parsons Ave., Suite 100

813.315.2080

TOWER Radiology Center - Sun City 3862 Sun City Center Blvd.

813.642.9299

TOWER Radiology CenterBruce B. Downs

3069 Grand Pavilion Dr.813.977.9777

TOWER Radiology CenterNorth Dale Mabry

17503 N. Dale Mabry Hwy.813.968.4540

TOWER Radiology CenterCarrollwood

14499 N. Dale Mabry Hwy., Suite 150813.968.6998

TOWER Radiology Center - HabanaTOWER Breast Diagnostic Center - Habana

4719 N. Habana Ave. 813.874.7000

TOWER Radiology Center - South Tampa2106 S. Lois Ave.

813.288.8839

TOWER Breast Diagnostic Center - Northside2716 University Square Dr.

813.971.2050

Scheduling Department HoursMonday – Friday 7:30 am to 7:00 pm

Saturday – 8:00 am to 12:00 pm(813) 874-3177

www.TowerRadiologyCenters.com

� Oldsmar • 3870 Tampa Rd., Oldsmar, 34677� Brandon • 414 W. Robertson St., Brandon, 33511� Brandon • 500 Vonderburg Dr., W. Tower, Ste. 111, Brandon, 33511� Brandon • 427 S. Parsons Ave., Ste. 100, Brandon, 33511� Bloomingdale • 3350 Bell Shoals Rd., Brandon, 33511� Riverview • 10689 Big Bend Rd., Ste. 102, Riverview, 33579� Sun City • 3862 Sun City Center Blvd., Sun City Center, 33573

� Wesley Chapel • 2324 Oak Myrtle Lane, Wesley Chapel, 33544� North Dale Mabry • 17503 N. Dale Mabry Hwy., Lutz, 33548� Carrollwood • 14499 N. Dale Mabry Hwy., Ste. 150, Tampa, 33618� Bruce B. Downs • 3069 Grand Pavilion Dr., Tampa, 33613� Northside • 2716 University Square Dr., Tampa, 33612� Habana • 4719 N. Habana Ave., Tampa, 33614� South Tampa • 2106 S. Lois Ave., Tampa, 33629

RADIOLOGY CENTERS