For more information about scheduling,
please feel free to contact us at any time.

Warwick • Scheduling (401) 921-2900 • Fax (401) 921-2909
Cranston • Scheduling (401) 490-0040 • Fax (401) 490-0049
North Providence • Scheduling (401) 533-9300Fax (401) 533-9309

East Providence • Scheduling (401) 431-0080Fax (401) 431-0018

Click here to download a PDF of this Form if you prefer

Patient Name:
We will contact the patient to complete scheduling for you.
 

*

     
Patient Telephone #:
 

*

     
Patient DOB:
 

*

     
Appointment
confirmation requested:
  yes no
Method of Confirmation:
 
Fax Call
  E-mail
     
Reason for Exam:.
 

*

     
Special Instructions: .
 

     
Referring Physician:
 

*

CC to:
 
     
Reports:
Call Report
Fax Report
Mail Report
E-mail Report
 
Images:
CD to Patient
CD to Physician

Film to Patient
Film to Physician
.
   
Brain Abdomen MRA Brain
Brain w/orbits (MS eval.) MRCP MRA Neck
Neck (soft tissue) Pelvis MRA Brain & Neck
C - Spine Shoulder L R 3D Reconstruction
T - Spine Knee L R  
L - Spine MR Arthrogram  
Other MRI
Other MRA
 
Head Abd/Pelvis CT Enterography
- Abd/Pelvis
Paransal Sinuses Renal (mass) - Abd/Pelvis
w/ & w/o contrast
and 3D Reconstruction
IAC/Middle Ear C-Spine w/3D
Neck (soft tissue) T-Spine w/3D
Chest (routine) CT Urogram (calculus)
Abd/Pelvis w/o contrast
L-Spine w/3D
Chest (high res for ILD.)  
Other 3D Reconstruction
Other CT
Other CTA
 
Abdomen w/Doppler OB 1st Trimester Breast
Renal & Bladder
(w/Doppler as needed)
OB 2nd/3rd Trimester L R Bil.
Thyroid DVT
Pelvis (w/transvaginal
as needed)
Carotid L R Bil.
Scrotum
(w/Doppler as needed)
 
Aorta w/Doppler  
Other Ultrasound
Other Doppler
 
Sinuses T - Spine Multi. Abd.
Chest L - Spine Pelvis
C - Spine KUB IVP
Other
 
Screening Mammography Diagnostic Mammography
Left Right Bilateral
 
DEXA (bone densitometry)
 
 

*Denotes required field.

 

 

 



The Imaging Institute

250 Toll Gate Road • Warwick, RI 02886
1301 Reservoir Avenue • Cranston, RI 02920
1500 Mineral Spring Avenue • North Providence, RI 02904
450 Veterans Memorial Parkway #8 • East Providence, RI 02914


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