General Order Form

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General Order Form

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(MD, NP, PA, etc.)
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General Exam Information
Exam(s) Requested









Reporting Instructions
Reporting instructions:
Exam Location(s)
Biopsy type:
Biopsy Location:
CT Location:
CT Angiogram Location:
DEXA Location:
Fluoroscopy Location:
Mammography Location:
MRI Location:
MR Angiogram Location:
Open MRI Location:
Ultrasound Location:
X-Ray Location:
PET/CT Location:

Mammography Information
Please note: screening mammograms (no breast symptoms). OIC recommends diagnostic mammography for patients with new breast symptoms and/or personal history of breast cancer diagnosed within the last 4 years.
Radiologist may determine workup to include additional imaging if needed.
Call my office prior to doing additional studies.
Ultrasound Information
Radiologist may determine workup to include additional imaging if needed.
Limited Doppler per Radiologist Protocol.
Call my office prior to doing additional studies.
PET/CT Information
To order a PET/CT exam, please fax a completed PET/CT order form to 541-334-7556. Download the form here. All PET/CT services, including oncologic and neurologic studies, are offered at our RiverBend Pavilion clinic.
CT Information
IV Contrast:
Without Contrast
With Contrast
With & Without Contrast
At Radiologist's Discretion
Notes:
If the answer is "yes" to any of the questions below, and the CT exam will require IV contrast, then lab values for BUN, Creatinine and GFR are required within 1 month of the scheduled exam. New labs are also required if a CT iodinated IV contrast study was performed within 48 hrs of a new CT iodinated contrast imaging study.

1. Patient 60 years or older
2. Kidney disease? (including single kidney, failure, transplant, renal cancer or renal surgery)?
3. Diabetic?
4. Hypertension requiring medical therapy?
5. Metformin containing drugs?
Recent Lab Values:
Notes:
Date: Creatinine:
Blood Urean Nitrogen (BUN):
Glomerular Filtration Rate (GFR):
Special CT Information
Iodine Allergy:
MRI Information
IV Contrast:
Without Contrast
With Contrast
With & Without Contrast
At Radiologist's Discretion
Notes:
Please Note: If your patient is claustrophobic, it is the referring clinician's responsibility to provide any prescription for the patient to take prior to their MRI exam.

If any of these questions are answered "yes" and the MR exam will require IV contrast, lab values for BUN, Creatinine and GFR within 6 weeks of exam are required.

1. Is the patient 60 or more years of age?
2. Does the patient have diabetes requiring medication?
3. Hypertension requiring medication?
4. Single/solitary kidney?
5. History of renal disease (i.e. renal tumor, failure, acute injury or transplant)?
6. Hepatorenal syndrome related to a liver transplant?
Recent Lab Values:
Notes:
Date: Creatinine:
Blood Urean Nitrogen (BUN):
Glomerular Filtration Rate (GFR):
Examination / Area(s) of Special Interest:
Signs & Symptoms / Clinical Indications / ICD Code: