Patient Name: ___________________________________________ DOB: ___________ Appt. Date: __________ Appt. Time: __________
Patient Phone: _________________ Referring Physician: ______________________________ SPECIAL REPORTING INSTRUCTIONS:
J E R E M Y N . W I E R S I G M . D . , P. A .
Addl. Referring Physicians: _______________________________________________________
❑ Films with Report to Office ❑ CD W/ Report
18802 Meisner Drive (OFF E. SONTERRA BLVD)
San Antonio, TX 78258 | TEL 210 572 2222 | FAX 210 249 2177
Diagnosis/Clinical History: ______________________________________________________
❑ Fax STAT Report: ______________________
423 Treeline Park, Suite 100 | San Antonio, TX 78209
Call Report: ❑ to Office ________ _________
Follow Up Doctor Appointment Date: _______________ Time: ____________________
Underlined Exams Usually Require Appointments
EXAMS REQUIRING SPECIAL PREPARATIONS & MAPS ON BACK
Previous Films & Location: ______________________________________________________
P E T C T (Stone Oak Only) B O N E D E N S I T Y S T U D Y ( D E X A ) ❑
❑ Skull Base to Mid-Thigh with CT Fusion*
Osteoporosis Scan ❑ Lateral Vertebral Assessment* ❑ Body Composition
❑ Per Radiologist ❑ Intra-articular Gadolinium (Joint)
❑ Whole Body (Melanoma) with CT Fusion*
D I G I T A L M A M M O G R A P H Y / See CT section to order a diagnostic CT studyB R E A S T D I A G N O S T I C S NUCLEAR MEDICINE w/plain films if needed (Stone Oak Only) Where______________________________ When__________________
❑ Gastric Emptying■ ❑ W/ Liquid ❑ W/ Solid
❑ Screening Mammogram (no symptoms) - w/ return work-up
❑ Unilateral Mammogram ❑ LT ❑ RT ❑ Galactography
❑ RBC Liver Hemangioma ❑ Thyroid Uptake & Scan■
S P E C I A L P R O C E D U R E S
❑ Joint Injection_______________ ❑ Biopsy*_______________________
_____________________________ ❑ Myelogram▲
R A D I O G R A P H Y (No Appointment Necessary)
(Required if >50 years or diabetic)U L T R A S O U N D
❑ Right Upper Quadrant■ ❑ Complete OB◆
❑ Ribs ❑ LT ❑ RT ❑ BIL FLUOROSCOPY
❑ Sinuses (Coronal) ❑ Abdomen/Pelvis▲,*
❑ Kidney (Renal) - Bilat.■ ❑ Fetal Biophysical Profile◆
❑ Biopsy*___________________ ❑ Cyst Aspiration*_______________
(Required if >50 years or diabetic)
❑ Fine Needle Aspiration*____________________________________
M R / C T A N G I O G R A P H Y V A S C U L A R U L T R A S O U N D S P E C I A L I N S T R U C T I O N S / A U T H # : E X A M P R E P A R A T I O N S
These preparations must be followed completely to ensure accurate test results. For the preparations for other procedures, please call our office.
Nothing to eat, drink, chew or smoke after midnight.
Nothing to eat, drink, chew or smoke 4 hours prior to exam.
Drink 32oz. of water 1 hour prior to exam (DO NOT VOID).
Special preparation required, call our office.
❑ CT SCAN: Please inform the scheduler if you are taking Glucophage, Glucovance, Metformin, Avandamet, or Metaglip. Nothing to eat or drink for 3 to 4
hours prior to exam time, (except for CT sinus). We will be calling you to ask you important questions regarding your medical history. Patients receivingoral contrast may experience diarrhea.
❑ CT SCAN (abdomen): If you have not picked up your oral contrast prior to exam, please arrive 1 hour early to receive the contrast agents for
❑ CT SCAN (abdomen and pelvis): If you have not picked up your oral contrast prior to exam, please arrive 2 1/2 hours early to receive the contrast
❑ MAGNETIC RESONANCE IMAGING (MRI/MRA): We will be calling you to ask you important questions regarding your medical history. *Do not wear
jewelry, hairpins, and barrettes for this exam.
FREE CITY-WIDE TRANSPORTATION AVAILABLE FOR PATIENTS UNDERGOING CT, MRI, AND PET EXAMS
SAN ANTONIO AREA MAP NORTH SAN ANTONIO MAP Visit our website for information about the imagingcenters and the procedures. Download and pre-print aregistration form and questionaires before your visit.
Camp Menzies Parent Letter to Counselor Girl Scouts Heart of Central California I 6601 Elvas Avenue Sacramento, CA 95819 I www.girlscoutshcc.org RETURN ALL PAPERWORK - No later than four weeks prior to camp session Please complete the information requested below. This will help camp staff “get acquainted” with each camper and know what both girls and parents/guardians expect from this
White’s Chapel United Methodist Church 2011-2012 ________________________________________________________________ ________________________ Child’s Name ________________________________________________________________ ________________________ Physician’s Name and Address In the event that I cannot be reached to make arrangements for medical treatment, I authorize any representative of W