Pre-Service/Outpatient Procedure - Ionia

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 616-523-1555.  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.

Thank you.

Sparrow Pre-Service
1-800-698-6329 or 517-364-3659, Monday - Friday 8pm - 5pm
  

Patient Information

*
Name:
*
Street Address:
*
City/State/Zip:
*
Date of Birth:
*
Gender:

Male or Female

*
Home Phone:
Work Phone:
Patients Email Address:
*
Can Sparrow Pre-Service speak with someone other than the patient to schedule the procedure.

Yes or No

Name:
Relationship to patient:

Guarantor Information

Guarantor First Name:
Guarantor Birthdate:
Guarantor Phone:
Authorization Number:

Insurance Information

*
Insurance Information
*
Date of Birth if other than Patient:
*
Policy Number:
*
Group Number:
Secondary Insurance:
Policy Holder/Subscriber Name:
Policy Number:
Group Number:

Clinical Information

*
Patient Weight:
*
History of allergy to Iodine or x-ray dye:

Yes or No

*
If yes you must document a reaction or we will be unable to schedule
Medications patient is taking:

Avandament, Glucophage, Glucovance, Glyburide, Metformin, Rosiglitazon

*
Is patient on blood thinners?

Yes or No

Ordering Physician Information

*
Physician name:
*
Office phone:
Office fax:
*
Office Contact:
*
Referring / Primary Care Physician:
Office Phone:
Office Fax:

Procedure Information

*
Procedure:
*
Diagnosis:
ICD9 Code:
Comments:
Common Radiology Exams:
Ultrasound of:
*
Are you scheduling a CT:

Yes or No

Cat Scan of:
*
Diabetic?

Yes or No

Is the patient 70 years or older?

Yes or No

Kidney disease?

Yes or No

Renal Insufficiency/failure?

Yes or No

Kidney surgery or kidney transplants?

Yes or No

Any kidney injuries?

Yes or No

Does he patient have any certain disease e.g. multiple myeloma/systemic lupus erythematosia?

Yes or No

Is the patient on potentially nephrotoxic medications e.g.? Chronic high dose NSAID therapy? Aminoglycoside antibotics?

Yes or No

Does the patient have any cardiovascular disease?

Yes or No

History of CHF?

Yes or No

Pheripheral vascular disease (PVD)?

Yes or No

If yes to any of the above questions. GFR results are required within 30 days for all outpatinet (IVE iodinated constrast ct scans only)

PT GFR Level?
Date Labs were drawn
Where were labs drawn at?
Patients must be ambulatory to have a CT Scan. Is the Patient Ambulatory?

Yes or No

Does the patient have prevoius history of allergy to x-ray dye?

Yes or No If yes, contact CT Sparrow 42155 with reaction. Clinton 73319 with reaction.

Has the patient been placed on a steroid prep?

Yes or No

Has the patient had any previous CT's or other exams pertaining to the study?

Yes or No

Where were the studies performed?
Bone Scan Type:

Total or Limited

Nuclear Medicine:
Scans:

Parathyroid Scan, 123 Thyroid Uptake Scan, HIDA Scan with Kinevac, HIDA Scan WITHOUT Kinevac, Other Radiology Exam (please specify)

Cardiology Exams

Cardiologist/Interpreter Name:
Cardiology Exams:

Stress Test, ECHO, Stress Echo, Dobutamine Stress Echo, Pulmonary Function, Holter Monitor, Other (please specify)

Cardiolite Type:

Adenosine, Dobutamine, Lexi Scan, Stress

Can patient walk a treadmill?

Yes, No, or Does Not Apply

For Holter Monitor, we must know if a patient has a pacemaker:

Yes or No

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