Physician Services
Exam Order Short Form
SimonMed Exam Order
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NPI:
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Patient Info
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Patient First Name:
 
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Patient Last Name:
 
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Phone:
 
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Date of Birth:
 
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Exam Details
Priority:
Normal
STAT
Modalities
Mammography
(Digital with CAD)
Screening
3D
(w/ follow up diag. mammogram & Ultrasound if indicated)
Diagnostic
3D
(w/ ultrasound if indicated)
Left
Right
Bi
Galactogram
Stereotactic Breast
Cyst Aspiration
Breast Biopsy
Dexa-Bone Density
Screening
(LVA as Indicated)
Body Comp
Ultrasound
(Doppler if indicated)
Abdomen
Breast/Axilla
Obstetric
Thyroid
Pelvis TA/TV
Renal/Bladder
Renal Only
Hysterosonogram
Scrotal
Prostate
Testicular w/ Doppler
Guided Biopsy
Vascular Studies
Carotid
Renal Artery
Arterial Legs
(w/wave form)
Arterial Arms
(w/wave form)
Venous Leg
Venous Arm
X-Ray
Abdomen
Chest
Foot
Knee
Ankle
Elbow
Hand
Wrist
Shoulder
Hip(w/pelvis)
Pelvis AP
Spine 3 Views
Spine 5 Views
Scoliosis
Sinus
Other
CT
(3D recon if indicated)(BUN/CR if indicated)
Abdomen
(w/pelvis if indicated)
Abdomen w/Pelvis
Kidney Stone (A-P w/o)
CT/IVP (urogram)
Chest
(CTA if indicated)
Lung Screen
Pelvis
(w/Abdomen if indicated)
Cardiac Score
CTA Coronary
Colon Virtual 3-D
Brain
Neck (soft tissue)
Sinus (maxillofacial)
Temporal Bones
Orbits
Spine
Extremity
:
CTA Brain (only)
CTA Neck/Brain
CTA (Other)
:
PET/CT
(IStat If Indicated)
Skull Base To Thigh 78815
Bone scan w NaF18
Whole Body(Melanoma) 78816
Brain 78608
PET/CT skull base to thigh w/contrast inc diagnostic CT
With:
Neck
Chest
Abdomen
Pelvis
Nuclear Medicine
Bone Scan
Spect Location
Plain films
(per rad as nec)
MUGA
HIDA
Parathyroid
Thyroid
MRI
3T
(3D recon if ind.,BUN/CR if ind.,Orbital X-Ray as needed)
Brain
w/MRA
IAC's
Pituitary
Orbits
Spine
TMJ
Neck MRA
Neck Soft Tissue
Brachial Plexus
Chest
Heart
Breast
wCAD3D
Abdomen
Pelvis
Prostate
Joint
MR Arthrogram
Extremity
MR Spectroscopy
MRA
MRV
Other
Fluoroscopy
IVP
(no tomo)
Esophogram
UGI
Small Bowel
UGI/SBFT
VirtualColon (CT)
BE
BE w/ air
Hysterosalphingogram
Other Modality
Specify Procedure:
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Diagnosis:
Additional Information:
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