769 CR 466 • Lady Lake, FL 32159352-261-5502 • 352-350-5942 Fax

SCHEDULING: 352-261-5502 oronline: www.MITFlorida.com

Patient Name DOB Male Female

Patient Phone Patient Email NKA or Allergies:

Authorization/Claim/Notification # BUN/CREATININE:

Referring Physician Physician Phone

Physician Signature Deliver Images Via: CD FAX:

Exam Date Exam Time EMAIL:

Clinical History/Diagnosis Additional Report to:

Special Instructions

High Field 1.5 Widest Bore MRIWith Contrast Without ContrastBoth Per Radiologist

PROVIDE CREATININE LEVEL ON CONTRAST EXAMS

BrainOrbitsBrain w/OrbitsIAC’s TMJPituitarySoft Tissue NeckChestBrachial PlexusCervical SpineThoracic SpineLumbar SpineAbdomenAbdomen w/ & w/o contrast - Adrenal ProtocolLiver Imaging w/ EOVIST ContrastMRCPRenalsUrography - Abdomen & PelvisPelvis - ProstatePelvis w/ & w/o contrast - Uterine FibroidPelvis - RoutinePelvis - Dynamic

XRAYSkullFacialTMJOrbitsSinusSinus/Waters1viewNasal BonesSoft Tissue NeckChest (CXR)Abdominal SeriesKUB

Extremities: qMRI qCT qXRAY

Other Exams Not Listed

Ultrasound

ThyroidBreastAbdominal Total

(Pancreas, Liver, GB, Kidney, Aorta, IVC, Spleen)

Retro-peritonealKidney/Bladder GB/Pancreas Liver (RUQ)Spleen (Left Upper Quadrant)

Special ExamsHysterosalpingogramJoint Injection __________________________ Lumbar PunctureThoracentesis - R L ParacentesisBiopsy _______________________________Drainage______________________________Radiologist to determine guidance method forBiopsy/DrainageConsultVascular Access - PICC Port Tunneled Cath.Catheter Check/ClearanceIVC Filter

MR ANGIOGRAPHYPROVIDE CREATININE LEVEL

Brain (COW) w/o contrastArch w/Carotid w & w/o contrastChest w & w/o contrastAbdomen w & w/o contrastPelvis w & w/o contrastRenals (w/MRI) w & w/o contrastMRA Run Off to include Pelvis & Lower Extremity w & w/o contrast MR Venography

SUBMIT FORM

Vein Care

Insufficiency UltrasoundEndovenous Laser AblationPhlebectomySclerotherapy

C Spine LimitedC Spine Complete w/Oblique and Flex/ExtT SpineL SpineL Spine Complete w/Flex/ExtScoliosisPelvisSI JointsSacrum/CoccyxOther ________________________

CT SCANWith Contrast Without ContrastBoth Per Radiologist

PROVIDE CREATININE LEVEL ON CONTRAST EXAMS

BrainTemporal Bones /IACS/MastoidsFacial BonesOrbits Sinus MaxillofacialSinus Coronal (limited)Soft Tissue NeckChest/Thorax w/o contrast (pulmonary nodule follow-up)Chest / Thorax - high resolutionAbdomen & PelvisAbdomenPelvisEnterography ProtocolKidney Stone Protocol - Abdomen & PelvisUrography Protocol - AbdomenCervical SpineThoracic SpineLumbar SpineOther_______________

CT ANGIOGRAPHYALL CTAs INCLUDE IV CONTRAST

PROVIDE BUN/CREATININE

Brain (COW)CarotidsChestChest PE ProtocolAorta ThoracicThoraco-Abdominal (Dissection)Abdominal AortaRenal Transplant EvaluationRenal ArteriesPelvisAbdominal Aorta w/RunoffUpper ExtremityLower Extremity (to include Pelvis) Vascular Ultrasound

Carotid Doppler Arterial Doppler w/ABI Lower Extremity: Bilateral Unilateral R L

Upper Extremity: Bilateral Unilateral R LAortaRenal Arterial DopplerSMA DopplerLiver Doppler

Venous DopplerLower Extremity: Bilateral Unilateral R L

Upper Extremity: Bilateral Unilateral R LVenous Insufficiency

Upper Extremities:

Lower Extremities:

Shoulder R L Bi Arthrogram Humerus R L Bi Elbow R L Bi Arthrogram Forearm R L Bi Wrist R L Bi Arthrogram Hand R L Bi

Hip R L Bi ArthrogramFemur R L Bi Knee R L Bi Arthrogram Lower Leg (tib/fib) R L Bi Ankle R L Bi Arthrogram Foot R L Bi

Renal Transplant w/DopplerPelvic TransabdominalPelvic w/TransvaginalOB TransabdominalOB w/TransvaginalTesticular Sono w/DopplerAppendixBladder