Patient Name: __________________________________________________________________ DOB: ______________________

Phone: ( ) - ____________________________ Allergies: qNKA ____________________

Diagnosis or Signs/Symptoms: 1._____________________________ 2. __________________________ 3. _______________________ ___

Ordering Please Physician OrderPhysician Print ________________________________ Signature ________________________________ Date ______________

PET/CT BREAST IMAGING

o PET/CT / Restagingo PET/CT / Evaluation to Therapy Response

Scheduling: (813) 874.3177 Fax: (813) 879.1809qTower Breast Diagnostic Center - Northside • 2716 University Square Dr.qTower Breast Diagnostic Center - Habana • 4719 N. Habana Ave.qTower Radiology Center - BBD • 3069 Grand Pavilion Dr.qTower Radiology Center - South Tampa • 2106 S. Lois Ave.qTower Radiology Center - Carrollwood • 14499 N. Dale Mabry Hwy., Ste. 150qTower Radiology Center -Wesley Chapel • 2324 Oak Myrtle LaneqTower Radiology Center - North Dale Mabry • 17503 N. Dale Mabry Hwy.qBloomingdale Radiology Center - Bloomindale • 3350 Bell Shoals RoadqCommunity Diagnostic Center - Brandon • 500 Vonderburg Dr., W. Tower, Ste. 111

BREAST MRI

o Breast MRI w/ & w/o contrast - Bilateral Diagnostico Breast MRI w/o contrast - Implant (Rupture)

BREAST BIOPSY

o Radiologist To Determine Guidance Method o Stereotactic Breast Biopsy R / L o Ultrasound Breast Biopsy R / L o MRI Breast Biopsy R / L

PELVIC MRI

o Pelvic MRI w/ & w/out contrast - Uterine Fibroido Pelvic MRI w/o or w/ & w/o contrast - Routineo Pelvic MRI w/o contrast - Dynamico Pelvic MRI w/o contrast - Fetal

BONE DENSITY

o DEXA SCAN ______________________________________o Vertebral Fracture Assessment o Body Composition

MAMMOGRAPHY• Please Note: Screenings Are For “No Breast Problems” Only• We ask that you bring any and all previous mammography

films with you at the time of your exam.

o Bilateral Digital Screening w / CAD and Bone Density/ DEXAo Bilateral Digital Screening w / CADo Bilateral Digital Diagnostic w / ultrasound (if necessary)o Unilateral Digital Diagnostic w / ultrasound (if necessary) R / Lo Additional ViewsIMPLANTS? o Yes o NoDOES THE PATIENT HAVE PREVIOUS FILM? o Yes o No

(First) (MI) (Last)

ULTRASOUND

o Breast o R o L If palpable mass, please indicate location: ______________o Transvaginalo Pelvico Pelvic Sono o With transvaginal if necessaryo OB Transabdominalo OB Transvaginal o OB Limited o OB Completeo Other __________________________________

o Other:

Appt. Date:___________________ Time:_________ A.M. P.M

For your convenience, you can also request an appointment online. To request anappointment, log onto www.TowerRadiologyCenters .com/appointmentrequest

EXAM PREPS AND MAP ON REVERSE SIDE

SERVICES MAY VARY BY LOCATION

q CC: Report To: ________________________

Rev. 2/12

Tampa’s First Imaging Center of Excellence

*ACR accreditations vary by modality

Designated by the American College of Radiology

MAMMOGRAPHY PATIENTS BEFORE YOU ARRIVE FOR YOUR EXAM:

• We strongly recommend that you bring any and all previous mammography and or ultrasound films with youat the time of your exam. These previous films will be used for comparison.

• If you must have your films delivered, please arrange for them to arrive at the facility at least 2 days priorto your appointment.

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TOWER Radiology CenterNorth Dale Mabry

17503 N. Dale Mabry Hwy.813.968.4540

TOWER Radiology CenterCarrollwood

Sport & Orthopedic Radiology Centerat Tower

14499 N. Dale Mabry Hwy.Suite 150

813.968.6998

TOWER Diagnostic Center1916 Highland Oaks Blvd.

813.909.7476

TOWER Radiology CenterWesley Chapel

2324 Oak Myrtle Lane813.751.0422

Within Cypress Creek Development

TOWER OpenScan MRIPalms

14525 Bruce B. Downs Blvd.813.972.0669

TOWER Breast Diagnostic Center - Northside2716 University Square Drive

813.971.2050

TOWER Radiology Center - HabanaBreast Diagnostic Center - Habana

4719 N. Habana Ave. 813.874.7000

TOWER Radiology Center - South Tampa2106 S. Lois Ave.

813.288.8839

TOWER Radiology CenterBruce B. Downs

3069 Grand Pavilion Dr.813.977.9777

Bloomingdale Radiology Center3350 Bell Shoals Road

813.654.4883

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Community Diagnostic Center of Brandon500 Vonderburg DriveWest Tower, Suite 111

813.654.5400

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Fax: (813) 879-1809

INSTRUCTIONS & PREPARATION:NPO: Nothing By Mouth

Please arrive 20 to 30 minutes prior to your scheduled appointment so that you will have time to fill out the necessary paperwork.

MAMMOGRAPHY:Do not use deodorant, perfume, or dusting powder before having your mammogram.BREAST BIOPSY:(Instructions for Stereotactic, Ultrasound and MRI)Arrive 1 hour prior to procedure. NPO 2 hours before exam (3 hours for MRI Guided Biopsy). No aspirin, fishoil, Vitamin E or aspirin containing products 7 days before and 2 days after procedure. You may take Tylenol.If you are on blood thinners (Coumadin, Plavix, etc.), contact our biopsy coordinator (813) 971-2050 ext. 236. Wear a two piece, comfortable, loose fitting outfit with a sports bra or bra without underwire. A bra is required.BREAST MRI:Bilateral Diagnostic: NPO 3 hours before exam. No estrogen or hormone replacement therapy (medication forHot Flashes ONLY) for 4 weeks prior to exam. Continue all other hormones (example: For Chemotherapy,Thyroid Disease, Birth Control, etc...). Implants: (Rupture) NPO 3 hours before exam. PELVIC MRI:Routine: NPO 3 hours before exam. Dynamic: Water ONLY 3 hours prior to exam.Fetal: NPO 3 hours before exam.ULTRASOUND:Pregnancy/Pelvic Sonogram: You must begin drinking about 1 hour prior to your exam time. Drink at least 32 ounces of liquid, stay away from caffeine drinks, over this time period. DO NOT go to the rest room; you must have a full bladder for your exam.DEXA SCAN:Please wear comfortable clothes, however refrain from wearing any metal accessories (i.e. zippers, buttons, etc.). No other preparation is necessary.

IMPORTANT - PLEASE NOTEAny woman who is pregnant or thinks she might be pregnant should let the technologist or doctor know before beginning her exam. If you need driving directions, log onto www.towerdiagnostic.com and click on the facility locations. Find the facility and click on “driving directions”.