Transcription of Computed Tomography (CT) Request Form
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Computed Tomography (CT) Request Form
<Fax to Diagnostic Imaging; fax numbers listed <Urgent/Emergent requests must bediscussed by direct consultation witha radiologistCurrent Patient ConditionDepartment Use OnlyDate format: yyyy-Mon-dd- Time format: hh:mmDate Received Time ReceivedDate of AppointmentTime of AppointmentMore info required oNo oYes Explain:Protocol: IV Contrast oNo oYesOral Contrast oNo oYesPriority oOP1 oOP2 oOP3 oOP4, Specify date:Clerk InitialRadiologist NamePreferred Facility00033 (Rev2017-06)Relevant Previous Imaging StudiesLocationTypeDate(yyyy-Mon-dd)Attached copyoNo oYesRenal Insufficiency oNo oYes On Dialysis oNo oYes run days:If no current results available, please indicate date ordered(yyyy-Mon-dd)Serum Creatinine (within 90 days)GFR Date (yyyy-Mon-dd)Specific anatomical area to be examinedRelevant clinical history/presumptive diagnosisClinical question to be answeredPatient label here or information below is requiredLast NameFirst NameBirthdate (yyyy-Mon-dd)GenderAddress ()
Title: Computed Tomography (CT) Request Form Author: Forms Strategy & Management Subject: Request Keywords: computed, tomography, CT, request…
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