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Order Form
Order Form
fraziercreative
2018-04-23T10:58:10-06:00
Please complete online form or download form and fax it to
877.481.0360
Patient Type
*
Home Health
Hospice
Long Term
Skilled
Stat or Routine
*
Stat
Routine
Sex
*
Male
Female
Patient's Name
*
Patient's Date of Birth
*
Phone
*
Facility
*
Facility Address
*
Room No.
*
Fax
*
Ordering Physician
*
Name of Person Calling In Order
*
Type of X-Ray
Please complete at least one field in this section or your order may not be dispatched.
Chest
L 71010 Chest, 1V
R 71010 Chest, 1V
L 71010 Chest, 2V, AP and Lateral
R 71010 Chest, 2V, AP and Lateral
L 71010 Chest, Apical Lordotic
R 71010 Chest, Apical Lordotic
Head/Neck
L 70100 Mandible, less than 4V
R 70100 Mandible, less than 4V
L 70140 Facial, less than 3V
R 70140 Facial, less than 3V
L 70160 Nasal, min 3V
R 70160 Nasal, min 3V
L 70210 Sinuses, min 3V
R 70210 Sinuses, min 3V
L Skull, less than 4V
R Skull, less than 4V
Ribs
L 71100 Ribs, Unilat 2V
R 71100 Ribs, Unilat 2V
L 71110 Ribs, bilat 3V
R 71110 Ribs, bilat 3V
L 71111 Ribs, Bilat w/chest, 4V
R 71111 Ribs, Bilat w/chest, 4V
L 71120 Sternum, 2V
R 71120 Sternum, 2V
Spine and Pelvis
L 72040 Cervical, 2V or 3V
R 72040 Cervical, 2V or 3V
L 72070 Thoracic, 2V
R 72070 Thoracic, 2V
L 72072 Thoracic, 3V
R 72072 Thoracic, 3V
L 72100 Lumbar, 2V or 3V
R 72100 Lumbar, 2V or 3V
L 72110 Lumbar, 4V
R 72110 Lumbar, 4V
L 72100 Lumbar, 2V or 3V
R 72100 Lumbar, 2V or 3V
L 72170 Pelvis, 1V or 2V
R 72170 Pelvis, 1V or 2V
L 72190 Pelvis, 3V
R 72190 Pelvis, 3V
L 72200 Sacroiliac Joints, less tha…
R 72200 Sacroiliac Joints, less tha…
L 72220 Sacrum and Coccyx, min 2V
R 72220 Sacrum and Coccyx, min 2V
Upper Extremities
L 73000 Clavicle
R 73000 Clavicle
L 73010 Scapula
R 73010 Scapula
L 73020 Shoulder, 1V
R 73020 Shoulder, 1V
L 73030 Shoulder, 2V
R 73030 Shoulder, 2V
L 73060 Humerus, 2V
R 73060 Humerus, 2V
L 73070 Elbow, 2V
R 73070 Elbow, 2V
L 73080 Elbow, 3V
R 73080 Elbow, 3V
L 73090 Forearm, 2V
R 73090 Forearm, 2V
L 73100 Wrist, 2V
R 73100 Wrist, 2V
L 73110 Wrist, 3V
R 73110 Wrist, 3V
L 73120 Hand, 2V
R 73120 Hand, 2V
L 73130 Hand, 3V
R 73130 Hand, 3V
L 73140 Finger, 2V
R 73140 Finger, 2V
Lower Extremities
L 73500 Hip, Unilateral, 1V
R 73500 Hip, Unilateral, 1V
L 73510 Hip, Unilateral, 2V
R 73510 Hip, Unilateral, 2V
L 73520 Hip, Bilateral
R 73520 Hip, Bilateral
L 73550 Femur, 2V
R 73550 Femur, 2V
L 73560 Knee, 1V or 2V
R 73560 Knee, 1V or 2V
L 73562 Knee, 3V
R 73562 Knee, 3V
L 73564 Knee, 4V
R 73564 Knee, 4V
L 73590 Tib/Fib, 2V
R 73590 Tib/Fib, 2V
L 73600 Ankle, 2V
R 73600 Ankle, 2V
L 73610 Ankle, 3V
R 73610 Ankle, 3V
L 73620 Foot, 2V
R 73620 Foot, 2V
L 73630 Foot, 3V
R 73630 Foot, 3V
L 73650 Calcaneus, 2V
R 73650 Calcaneus, 2V
L 73660 Toe, 2V
R 73660 Toe, 2V
Abdomen
L 7400 KUB, 1V
R 7400 KUB, 1V
L 74010 KUB, AP, Oblique, Cone
R 74010 KUB, AP, Oblique, Cone
Other
Symptoms
Please complete at least one field in this section or your order may not be dispatched.
Abdomen
Abdominal Pain R10.9
Abdominal Obstruction K56.60
Skull
Face/Head R51
Nasal J34.89
Sinusitis J32.9
EKG
Angina I20.9
Arrhythmia I49.9
Bradycardia R00.1
Tachycardia R00.0
Pain
Ankle M25.57
Coccyx M53.3
C-Spine M54.2
Elbow M25.52
Femur M79.65
Foot M79.67
Forearm M79.63
Hand M79.64
Hip M25.55
Humerus M79.62
Knee M25.56
L-Spine M54.5
Pelvis M25.559
Ribs R07.89
Shoulder/Clavicle M25.51
T-Spine M54.8
Tib/Fib M79.66
Wrist M25.53
Chest
Congestion R09.89
Cough R05
Fever R50.9
Pain R07.9
Picc Z95.9
Positive PPD R76.11
Rales R09.89
S.O.B. R06.02
Wheezing R06.2
Special Instructions
Comments
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