1241 Woodland Avenue
Mt. Pleasant, SC 29464

Phone: (843) 881-4020
Fax: (843) 881-7515

info@imagingsc.com

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Patient Name*:
Address*:
City*: State*: Zip*:
Date of Birth*:
Phone #*:
Insurance Provider*: Policy Number*:
Reason for test*:
Exam Information
  Open 3T MRI Digital XRAY
  MRA DEXA Bone Densitometry
  CT Ultrasound
  Digital Mammography Other:
  Contrast: Yes No As Needed
Head, Neck & Spine
  Brain Lumbar Spine
  Orbits Thoracic Spine
  Sinuses Spine Survey
  Cervical Spine Other:
Extremities
 
Arm: Right Left Hip: Right Left
Leg: Right Left Knee: Right Left
Ankle: Right Left Shoulder: Right Left
Elbow: Right Left Wrist/Hand: Right Left
Foot: Right Left      
  Other:
Body
  Abdomen/Pelvis MRCP (Billary Study)
  Chest  
  Soft Tissue Neck Other:
Women's Care
  Mammography screening (Diagnostic/Ultrasound if indicated)
  Mammography diagnostic (Ultrasound if indicated)
  Pelvis, OB OB, 1st Trimester
  Other:  
 
Breast MRI Biopsy (CAD Guided) Right Left Bilateral

Breast Ultrasound

Right Left Bilateral
SPECIAL PROCEDURES
  Biopsy/Aspiration Epidural Steroid Injection
  Arthrogram Selective Nerve Root Block
  Interventional Consult Varicose Vein Consult
  Arterial Consult Other:
 
Referring Physician Information
Referring Physician*:
Office Name*:
Office Phone*:
Office Fax*
Email Address *
Special Instructions
 
Note: Please fax a copy of the front and back of the patient’s insurance card to Imaging Specialists of Charleston at (843) 881-7515

Our state of the art open 3T MRI is the second of its kind in the country.

 

 

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