X-ray Order Form

*Ordering Facility:
*Room #:
*Ordering Doctor:
*Patient Name:
*Patient Phone:
Patient Email:
Exam:
Exam Date (If other than today):
*Facility Phone:
Fax # For Final Report:
Diagnosis:
*Hospice:

Upper Extremeties

Left Clavicle, 2 view
Right Clavicle, 2 view
Left Shoulder, 1 view
Right Shoulder, 1 view
Left Shoulder, 3 view
Right Shoulder, 2 view
AC Joints
Left Humerus, 2 view
Right Humerus, 2 view
Left Elbow, 2 view
Right Elbow, 2 view
Left Elbow, 3 view
Right Elbow, 3 view
Left Forearm, 2 view
Right Forearm, 2 view
Left Wrist, 2 view
Right Wrist, 2 view
Left Wrist, 3 view
Right Wrist, 3 view
Left Hand, 2 view
Right Hand, 2 view
Left Hand, 3 view
Right Hand, 3 view
Left Fingers, 2 view
Right Fingers, 2 view
Left Shoulder to Hand
Right Shoulder to Hand

Lower Extremeties

Pelvis, 1 view
Pelvis, 3 view
Left Hip, 1 view
Right Hip, 1 view
Left Hip, 2 view
Right Hip, 2 view
Left/Right Hips and Pelvis, 4 view
Left Femur, 2 view
Right Femur, 2 view
Left Knee 1 or 2V, 1 view
Right Knee 1 or 2V, 1 view
Left Knee, 3 view
Right Knee, 3 view
Left Knee, 4 view
Right Knee, 4 view
Left Tib/Fib, 2 view
Right Tib/Fib, 2 view
Left Ankle, 2 view
Right Ankle, 2 view
Left Ankle, 3 view
Right Ankle, 3 view
Left Foot, 2 view
Right Foot, 2 view
Left Foot, 3 view
Right Foot, 3 view
Left Calcaneus, 2 view
Right Calcaneus, 2 view
Left Toes, 2 view
Right Toes, 2 view
Left Hip to Foot
Right Hip to Foot

Head

Left Mandible, 3 view
Right Mandible, 3 view
Facial Bones, 2 view
Facial Bones, 3 view
Nasal Bone, 3 view
Left Orbits, 4 view
Right Orbits, 4 view
Left Sinuses, 2 view
Right Sinuses, 2 view
Sinuses, 3 view
Skull, 3 view
Skull, 4 view
Left TM Joint, 2 view
Right TM Joint, 2 view

Thorax

Chest, Frontal, 1 view
Chest, 2 view
Chest Special, 1 view
Left Ribs, 2 view
Right Ribs, 2 view
Left Ribs and CXR, 3 view
Right Ribs and CXR, 3 view
Bilat Ribs and CXR, 4 view
Sternum, 2 view
S/C Joints, 3 view
AP ABD, 1 view
ABD, Flat and Up, 2 view
ABD, 2V and 1V CXR, 3 view
B-Read, 4 view
B-Read 1V, 1 view
PICC Line Placement

Spine

Spine, 1 view
Cervical, 2 view
Cervical, 4 view
Thoracic, 2 view
Thoracic, 3 view
Thoracic, 4 view
Lumbar, 2 view
Lumbar, 5 view
S/I, 2 view
SAC/COCC, 2 view