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History / Symptoms

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X-ray (
Walk-in basis ONLY, NO APPOINTMENTS
) __________________________________________________________________________________
Fluoroscopy ______________________________________________________________________________________________________
DEXA ____________________________________________________________________________________ ADD Vertebral Height
CTA _____________________________________________________________________________________ CTA Chest (PE)
CT _______________________________________________________________________________________ WO W/
NOTE: CT Lung Cancer Screenings require a separate request form to be completed to schedule. Contact DR for more info.
CT Calcium Scoring CT Colonography CTU  abd/pelvis w/wo IV CTE  abd/pelvis w/ IV
NOTE: CT Calcium Score / CT Colonography may not be covered by insurance, including Medicare. Cash price available, call DR for more info.
___________________________________________________________________________________ WO W & WO Arthrogram
____________________________________________________________________________________________ WO W & WO
____________________________________________________________________________________________ WO W & WO
__________________________________________________________________________________________________
Biopsy Other (specify) ________________________________________________________________________________________________
 ________________________________________________________________________________________________________
 US Segmental Pressures  US Arterial Duplex US Pelvic & T-Vag
US Pelvic US T-Vag

(Skull to Thigh) PET/CT Brain (Melanoma, Extremity Metastasis)
Angiography _______________________________________________________________________________________________________
CT Biopsy _________________________________________________________________________________________________________
 ______________________________________________________________________________________
____________________________________________________________________________ DOB_________________________
Ph___________________________________ Cell Ph ____________________________________ Work/Alt ____________________________
______________________________________________________________ Policy #______________________________________
______________________________________________________________
History / Symptoms
(required)______________________________________________________________________________________________
 ____________________________________________________________________________________________________
__________________________________________________________________________________________________
Ph ___________________________ Fx ___________________________ CC Physician ___________________________________________
__________________________________________ _________________________
   Other __________________________________
Please be sure to bring your health insurance card, picture I.D. and co-payment with you, as well as any x-ray studies pertaining to your scheduled exam. If you might be pregnant, please contact our scheduling department or nofy the
technologist before your exam. Visit our website for informaon regarding preparaons for your examinaon or lab tests required. Por favor, asegúrese de traer su tarjeta de seguro de salud, foto I.D. y copago con usted, así como cualquier
estudio de rayos X relacionado con su examen programado. Si puede estar embarazada, comuníquese con nuestro departamento de programación o noque al técnico antes de su examen. Visite nuestro sio web para obtener información
sobre los preparavos para su examen o las pruebas de laboratorio requeridas.





For paent exam prep instrucons visit us at DesertRad.com or call our Paent Care Center at 702-759-8600.
Para las instrucciones de preparación para el examen del paciente, visítenos en línea en DesertRad.com o llame a nuestro Centro de Atención al Paciente al 702-759-8600.





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History Symptoms

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Completed 14 May 2021

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