Clinical History/Reason for Exam:

Insurance Information: Patient’s Phone:

Referring Physician (please print): Physician Signature:

Phone:Patient to bring images to Doctor

Call in STAT resultsAfter hours contact#: ______________________________

CTMRI

With & Without ContrastWithout ContrastBrainNeuroquantSoft Tissue NeckOrbitsFaceSpine: __Cervical __Thoracic __Lumbar

Arthrogram (Direct)

Prostate

MR AngiographyHead-Circle of Willis (w/o Contrast) Neck (Carotids)Abdomen (Renals)Abdominal AortaThoracic AortaLower Extremities w/Runo�sOther: _________________________

Diagnostic CTWith Contrast

Without Contrast

SinusesBrain/Head

Facial Bones/Maxillo FacialTemporal Bones/Ear/OrbitSoft Tissue (Neck)Spine: __Cervical __Thoracic __LumbarPost Mylogram: __Cervical __Thoracic __LumbarLow Dose Lung (Chest) __Screening __Follow-upCalcium Scoring (w/o Contrast)

Cardiac MorphologyAbdomenPelvisEnterographyCT UrogramJoint: _____________ __Left __RightExtremity: ___________ __Left __RightBiopsy______________________

Other: _________________________

CTA (Angiography)Head (Circle of Willis)Neck (Cartorids)Abdominal AortaThoracic AortaCoronary CTATAVRAbdomen/PelvisLower Extremities Runo�s

ULTRASOUND

PET/CT

Abdomen CompleteRenal

X-RAY/FLUOROSCOPYChestAbdomen (KUB)SkullPelvisScoliosis SeriesSpine: __Cervical __Thoracic __LumbarHands: __Left __RightWrist: __Left __RightHip: __Left __RightKnee: __Left __RightAnkle: __Left __RightFoot: __Left __RightShoulder: __Left __RightLong Bone: ___________ __Left __RightEsophagramSmall Bowel Series/SBFTUpper GIBarium EnemaHysterosalpingogramVoiding CystourethrogramOther: _________________________

INTERVENTIONALConsultation

DEXABone Density Screening

Vertebroplasty/KyphoplastyLevel: _________________________DiscogramLevel: _________________________Myelogram: __Cervical __Thoracic __LumbarLumbar PunctureEpiduralLevel: _________________________PICC Placement: __Eval __ExchangeCentral Dialysis Cath:__Eval __Exchange __Insert __RemovePort-O-Cath: __Placement _RemovalThrombectomyAnatomy: ______________________Drain: __Placement __RemovalVenogramAnatomy: ______________________AngiogramAnatomy: ______________________FistulogramOther: _________________________

Renal/BladderABD LimitedProstateRenal TransplantThyroidSoft Neck TissueScrotum/TesticlesPelvic Transvaginal only (non-ob)Pelvis w/o Transvaginal Pelvis w/ TransvaginalOBTVS < 13 WeeksObstetrical CompleteObstetrical LimitedOB Multiple GestationsMale PelvisOther_____________________

Breast UltrasoundBilateral Complete

Limited: __Left __Right

ABI’sDuplex ABD Retroperteum

Complete: __Left __Right

Arterial UltrasoundCarotid

Upper Extremity: __Left __Right __BilateralLower Extremity: __Left __Right __Bilateral

Aorta

Biopsy UltrasoundParacentesis

LiverThoracentesis

Breast: __Left __RightOther: _________________________

Thyroid

Venous UltrasoundVenous Doppler Lower Ext:__Left __Right __BilateralVenous Doppler Upper Ext:__Left __Right __BilateralRe�ux Examination__Left __Right __BilateralVein Mapping (Upper)__Left __Right __BilateralGroin

Thyroid Whole BodyThyroid Whole Body with ThyrogenThyroid Uptake/ScanParathyroidHIDA Scan

Gallium ScanRenogram: __Captopril __Lasix

Bone Scan: __Total __Limited __3 PhaseDAT Scan (Parkinson’s)Myocardial Pref (Sestambi)__Treadmill __Lexiscan

__Without injection fraction__With injection fraction (Ensure)

Plumonary Perf and VentGastic Emptying Study: __Solid __LiquidOther: _________________________

Mid Skull/Mid ThighBrain/AlzheimersMelanoma/Thyroid Cancer (Head-Toe)Other: _________________________

MAMMOGRAPHYImplantsMammography (3D Tomo available)__Screening __Diagnostic__Left __Right __BilateralBreast Ultrasound if indicatedMammo Strereotactic Biopsy

Please bring this form and your insurance card with you on the day of your exam.

MR

NUCLEAR MEDICINE

KERN_STANDARD_NEW_REV10282020VER2MC

Schedul ing P: (661) 324-7000 | F : (661) 334-3164

Appointment Date:

Patient’s Name:

Appointment Time: Today’s Date:

Date of Birth:

With & Without Contrast

CT Biopsy

Abdomen (Renals)

ChestHRCT Chest

AbdomenMRCPBreast BilateralPelvis

Brachial Plexus: __Left _Right

Hips: __Left _Right

Joint: ____________ __Left __RightLong Bone: __________ __Left __Right

ColorectalOther: _________________________

FAX this order and clinical records to:

Maps and Addressesare located on theback of this form[ ]

BAHAMAS FACILITY2301 Bahamas Dr.Bakers�eld, CA 93309

RIO BRAVO FACILITY4500 Morning Dr., #202Bakers�eld, CA 93306

RIVERWALK FACILITY9330 Stockdale Hwy., #100Bakers�eld, CA 93311

OLD RIVER FACILITY9900 Stockdale Hwy., #100, #109Bakers�eld, CA 93311

SAN DIMAS FACILITY3838 San Dimas, #A-120Bakers�eld, CA 93301

TEHACHAPI FACILITY432 South Mill Street,Tehachapi, CA 93561(X-Rays ONLY)

DOWNTOWN FACILITY1817 Truxtun Ave.,Bakers�eld, CA 93301

DOWNTOWN ADVANCED FACILITY1818 16th Street,Bakers�eld, CA 93301

KernRadiology.com

KERN RADIOLOGY REFERRAL FOR IMAGING SERVICES

• Please be advised; failure to present this imaging request at the time of your appointment may result in cancellation and rescheduling of your exam.• Arrive at the speci�ed time to allow for registration and exam preparation.• Notify us upon arrival of any special needs or allergies• You may take and prescribed medication as usual unless speci�ed at the time of scheduling.

• Bring your ID, insurance card and authorization of workers comp information.• Co-pay, co-insurance and/or deductables will be collected at time of service.• Wear comfortable clothing.• Leave valuables at home (Kern Radiology) is not responsible for lost or stolen articles.

• Please allow 1-2 hours for MRI examinations• Alert the technologist if you have ever had metal objects or shavings in your eye.• Remove any jewelry, piercings or valuable items before arriving to your appointment (wedding ring is ok).

• Do not use powder, perfume or deodorant on the day of your exam.• Wear a 2 piece out�t.

• If you are taking calcium and/or other supplements, do not take any 24 hour prior to your exam.

PELVIC/OB/BLADDER • You must �ll your bladder by drinking 32oz. of water, 60 minutes prior to your exam. • DO NOT empty your bladder.ABDOMINAL • Do not eat or drink six (6) hours prior to your exam.

• Please allow 2-3 hours for pet examinations• All diabetic patients should contact Kern Radiology to obtain guidelines on diet and medication restrictions prior to their pet scan• Neurologic studies: no food or liquid for a minimun of six (6) hours prior to arrival. Please check with referring physician regarding all medications you are taking.• Cardiac studies to access cardiac viability: patients should have a high carbohydrated breakfast prior to arrival for their pet scan (e.g. pancakes, cereal, etc).• Body/oncology: no food or liquid for a minimum of six (6) hour prior to arrival for your pet scan, You may have water and normal medications.

• If you are scheduled for a myelogram or a biopsy, do not eat or drink six (6) hours prior to your arrival time. Low Dose Lung (Chest) Screening Follow-up• If you are scheduled for any type of CT Abdomen, CT Pelvic or CT Abdomen/Pelvic with or without contrast, do not eat four (4) hours prior to your arrival time.

General Patient Information

Exam Speci�c Information

General Location & Maps

>>if there is any possibility of pregnancy, please inform our sta� prior to your appointment