INTERVENTIONAL RADIOLOGY DOB: Date: INVASIVE …

1 Name: _____. MRN:_____. INTERVENTIONAL RADIOLOGY DOB:_____ Date: _____. INVASIVE PROCEDURE CONSULT FORM. Procedure date/time:_____. INTERVENTIONAL RADIOLOGY Scheduling Number: (806) 775-8770; Fax Number: (806) 775-8719. INTERVENTIONAL RADIOLOGY INVASIVE PROCEDURE CONSULT FORM. _____. Special Instructions: A minimum 2 hour recovery time for outpatient procedures/NPO after midnight the night before the procedure. Paracentesis/Thoracentesis/Thyroids & Venograms do not require patients to be NPO or recovery time. (All procedures will be reviewed by Radiologist prior to scheduling). Abdominal/Retroperitoneal Mass Biopsy Lymph Node Biopsy: Location:_____. Ablation of _____(Microwave/Cryo) Mediastinal Mass Biopsy Abscess Drain: Location: _____ Neck Mass Biopsy Nephrostomy Tube (Placement/Exchange)(Right or Adrenal Biopsy (Right or Left).)

2 Left or Bilateral). Angiogram (Hepatic/Mesenteric/Pelvic/Renal/Splenic ) Paracentesis (Please specify if labs on fluid req). Angiogram (Upper Extremity/Lower Extremity). Pelvic Mass Biopsy (Right or Left or Bilateral). Biliary Drain (Placement/Exchange) Peripherally Inserted Central Catheter (PICC). Bone Biopsy: Location: _____ Pleurx (Pleural/Peritoneal)(Right or Left). Cerebral/Carotid Angiogram Port (Placement/Removal). Chest Tube (Placement/Exchange/Removal) Renal Biopsy (Right or Left). Cholecystostomy Drain (Placement/Exchange/Removal) Thoracentesis (Please specify if labs on fluid req). Fistulogram/AV Declot (Right or Left) Thyroid Biopsy G-Tube/J-Tube/G-J Tube Replacement Transjugular Intrahepatic Portosystemic Shunt (TIPS). IVC Filter (Placement/Removal) Tunneled Catheter Kyphoplasty/Vertebroplasty:Level(s):____ _ Tunneled Dialysis Catheter Liver Biopsy (Percutaneous/Transjugular) Ureteral Stents (Right or Left or Bilateral).

3 Liver Chemo Embolization/TACE Other:_____. Lung Biopsy (Right or Left). Diagnosis/Signs & Symptoms: _____. (Must have a diagnosis/signs & symptoms listed). _____Labs: (not older than 2 weeks BMP, CBC w/ Diff, PT/PTT/INR). Determine if patient is taking an anti-platelet or anti-coagulant ( warfarin, aspirin, clopidogrel, dabigatran, etc.). Contact INTERVENTIONAL RADIOLOGY for holding instructions. _____H&P (Must be within 30 days of scheduled procedure & faxed along w/order request) NPO: _____. Allergies: _____. Any Images to support findings: UMC Films: _____ Outside Films: _____. Referring Clinic & Physician:_____. Clinic Contact Name & Number:_____ _____. *Physician Signature_____ Date/Time_____. * Physician signature required Page 1 of 1- INTERVENTIONAL RADIOLOGY Consultation Form 02/21/2017 (V-6).