CRL Referral Form Your AppointmentDates and times are tentative until appointment is confirmed.Requested Date Requested Time : HH MM AM PM Location*CRL Imaging PlymouthCRL Imaging Southdale/Women's ImagingScheduling/Special Instructions* CRL to call patient to schedule CRL to call referring office to schedule Read and call report CRL to send copy of images with patient Other Please Explain*Patient InformationPatient Name* First Last Date of Birth* Home Phone*Work or Cell Phone*Clinical HistoryDiagnosis*Patient MRI Safe?*No Pacemaker, Aneurysm Clips, Defibrillator, etc.YesNoKnown Allergies*Previous surgery of anatomy to be scanned?*YesNoDate of Surgery* Patient InsuranceInsurance CompanyPolicy #Group #Check if applicable Personal Injury / Auto Injury Workers Compensation Personal Injury / Auto Injury DetailsClaim #PhoneDate of Injury Workers Compensation InformationEmployerAdjuster's NameClaim #Insurance CompanyPhonePhysician InformationName of Referring Physician*Clinic Name*Office Phone*Office FaxExam InformationExam Type and Location* MRI - P MRA - P CT - P CTA - P Virtual Colonoscopy - P Myelogram - P FNA - P / SD MRI Enterography - P MRI Arthrogram - P CT Lung Screening - P Cardiac Calcium Scoring - P X-Ray - P / SD Pain Management Injection - P Ultrasound - P / SD Mammography/Breast Imaging - SD Breast MRI - P Abbreviated Breast MRI - P Bone Density (DXA) - SD Pain Management Injections* SI Joint Facet Trigger Point Injection Synvisc Injection Nerve Root Block Epidural Steroid Injection Myelography Bursa Joint Other - Please Specify Other - Pain Management Injections*Ultrasound* Abdomen Renal Pelvic Venous Scrotum Liver Thyroid Aorta Paracentesis Carotid OB Other - Please Specify Abdomen* Complete Limited Renal* w/Doppler Bladder Pelvic* w/Doppler Follicle Venuous* Right Left Scrotum* w/Doppler Liver* w/Doppler Thyroid* FNA Aorta* ABI OB* Biophysical Measurements < 14 Weeks > 14 Weeks Ultrasound - Paracentesis Therapeutic Diagnostic Both Other - Ultrasound*X-Ray* Cervical AP, Lat & Open Mouth (3 view) Cervical- 3 View, w/ Flexion & Ext. Davis Series (7 Cervical Views) Thoracic AP & Lateral (2 Views) Thoracic — 2 View w/ Swimmers View Lumbar AP & Lat w/ Lat L5-S1 Spot (3 View) Lumbar — 3 View w/ AP Pelvis Lumbar — 3 View w/ Obliques Lumbar — 3 View w/ Flexion & Ext Full Spine — 36" AP & Lateral - P Other - Please Specify Other - X-Ray*Mammography/Breast Imaging* Mammogram Upright Stereotactic Biopsy Ultrasound Guided Breast Biopsy Breast Ultrasound Ultrasound Guided Cyst Aspiration Type* Screening (Asymptomatic) Diagnostic Full Diagnostic Which technology do you prefer?* 2D (Digital) Mammography 3D Mammography (Tomosynthesis) Patient Preference Area of Concern: Left Breast Right Breast Bilateral Other - Please Specify Area of Concern - Other:*Abbreviated Breast MRI*Please note this is an out of pocket expense at a flat rate for the patient - please call for quote. Patient must arrive 15-30 minutes prior to the exam to fill out paperwork. Does the patient have anything metal or foreign in their body, accidentally or surgically?* Yes No Is there a history of breast cancer or radiation to the chest wall (i.e. Hodgkin's Lymphoma)* Yes No Is the patient BRCA Positive?* Yes No Has the patient had a negative or benign mammogram in the past 12 months?* Yes No Is the patient considered high risk (greater than 20% lifetime risk)?* Yes No Is the patient claustrophobic?** Please note if the patient has a history of glaucoma, no valium can be given. Yes - Will provide own medication (preferred) Yes - CRL to provide medication No Due to your answer above, the patient may be considered high risk. Please call us after submitting this form at 763-509-4720 (Plymouth) or 952-285-3720 (TCMI Edina) and we will further assist you with your specific imaging needs.Please select an area Body Extremities Head & Neck Spine Other - Please Specify Other - Specify Views*Area(s) to be examined:Area to be examined Body Head & Neck Extremeties Spine Other - Please Specify Other - Specify Views*Body Chest Abdomen Pelvis Abdomen/Pelvis Other - Please Specify Head & Neck Head Neck Sinus TMJ Pituitary Orbits IAC Other - Please Specify Extremities Shoulder Elbow Wrist Hand/Finger Knee Tibia/Fibula Ankle Foot/Toe Hip/Pelvis Other - Please Specify Other - Specify Views*Shoulder* Right Left Bilateral N/A Elbow* Right Left Bilateral N/A Wrist* Right Left Bilateral N/A Hand/Finger* Right Left Bilateral N/A Knee* Right Left Bilateral N/A Tibia/Fibula* Right Left Bilateral N/A Ankle* Right Left Bilateral N/A Foot/Toe* Right Left Bilateral N/A Hip/Pelvis* Right Left Bilateral N/A Other - Specify Views*Spine Cervical Thoracic Lumbar Other - Please Specify Spine - Views AP & Lateral Flex & Ext Oblique Other - Specify Views*Special InstructionsCAPTCHAEmailThis field is for validation purposes and should be left unchanged.