RADIOLOGY REQUEST FORM
Angio Interventional
& Neuro Interventional
Patient’s Name (Last, First) Date of Birth
Patient’s Phone Number Weight
List Any Allergies Diabetic Yes No
Symptoms/Reason for Exam ICD-10 Code(s)
____________________________________________________________________________________________________________
PLEASE NOTE: Procedures will NOT be performed without a complete and signed order.
HEAD/NECK/SPINE ANGIOGRAPHY CHEST, ABDOMEN AND PELVIS
UPPER EXTREMITIES LOWER EXTREMITIES
NEURO SPINE SPECIAL/MISCELLANEOUS
____________________________________________________________________________________________________________
NPI#
Ph
one
Ordering Provider
(Print Name and Title)
Signature
(Required)
Date
Fax
Please FAX the completed form to the appropriate modality, then call for an appointment.
Angio Interventional
FAX 909-558-0388
Phone 909-558-5835
Neuro Interventional
FAX 909-558-0335
Phone 909-558-4394
You ca
n place orders and view results faster using llucarelink.org. Learn more at:
http://lluhconnection.org/loma-linda-university-health-carelink.
General Arterial (Select item)
General Arterial (Select item)
General Venous (Select item)
General Venous (Select item)
Dialysis Access (Select item)
Vascular Interventional (Select item)
Spine Injection (Select item)
New Consult (Select item)
