This service is not intended for STAT or ASAP procedure requests.
CTA (CT angiography), MRI's, and Interventional Radiology cannot be requested using this form.
If you need to schedule an MRI or PET scan please call 517-364-2877.
If you need to schedule Tilt Tables or Tee's you need to contact the cardiologist group you want to perform the procedure. If you are the cardiologist group then call Pre-Service.
All Nuclear Medicine require a prescription your office must fax an order to Ionia radiology at 517-364-3775. Failure to fax an order may result in the procedure getting canceled.
Important Notes: For ANY procedure requiring sedation, Sparrow Pre-Service must be called prior to scheduling.
There is a 24 to 48 hour turn-around time on each request submitted.
Please read each field carefully before submitting.
1-800-698-6329 or 517-364-3659, Monday - Friday 8pm - 5pm
****IF THIS IS FOR A BIOPSY OR ANY OTHER INTERVENTIONAL PROCEDURE YOU NEED TO GO BACK AND CHOOSE THE INTERVENTIONAL RADIOLOGY/IR CONSULT FORM. IF NOT THIS ORDER WILL BE FAXED BACK TO YOU AND YOU WILL HAVE TO EITHER CALL THE ORDER IN OR RE-DO ORDER WITH THE PROPER FORM.*****
Male or Female
Yes or No
Avandament, Glucophage, Glucovance, Glyburide, Metformin, or Rosiglitazone
Sparrow Hospital, SPB - Diagnostic Center, St. Lawrence Campus, Sparrow Clinton Hospital, Okemos Diagnostic, Ramblewood Imaging Center, Other (please specify)
Mammogram, B.E., UGI, IVP, Esophagram, Small Bowel Study
Neck/Thyroid, Neck Lymphadenopathy Exam
Cervical, Thoracic, Lumbar
Yes or no
Total or Limited
Parathyroid Scan, 123 Thyroid Uptake Scan, HIDA Scan with Kinevac, HIDA Scan WITHOUT Kivevac, EEG, Other Radiology (Please Specify)
MSU Cardiology, Dr. Nagappan, Dr. A J Shah, Sparrow Hospitalist, Thoracic Cardiovascular Institute (TCI), Other (please specify)
Stress Test, ECHO, Stress Echo, Dobutamine Stress Echo, Pulmonary Function, Pediatric Echo, EKG, Holter Monitor, Other (please specify)
Adenosine, Dobutamine, Lexi Scan, Stress
Yes, No, or Does Not Apply
14 Day or 30 Day