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Collects patient demographics, ordering physician/provider details, signs and symptoms (ICD DX code), exam selection, scheduling/contact information, results routing, and prior-exam and study preparation requirements. Lists exam categories with CPT codes such as radiology, CT, MRI/MRA, ultrasound, ultrasound OB/GYN, spine/pelvis, nuclear medicine, arterial/venous Doppler, and CTA options. Provides preparation guidance for radiology and ultrasound procedures.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/providence-st-peter-hospital-diagnostic-imaging-department-completed-order-form-fax-completed-order-to-360-493-5236/307765/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/providence-st-peter-hospital-diagnostic-imaging-department-completed-order-form-fax-completed-order-to-360-493-5236/307765.png","ImageObject",442,249,{"name":88,"@type":89},"Blitz","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-23","2026-09-19",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",22,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"Where should the completed order be faxed?","Question",{"text":109,"@type":110},"Fax the completed order to 360-493-5236, as indicated on the form.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"What information is required for the scheduled study section?",{"text":114,"@type":110},"The form requests prior-exam relation details, recent labs for contrast studies, creatinine date and faxed copy, medication/contrast allergy status, and patient weight for specified exams.",{"name":116,"@type":107,"acceptedAnswer":117},"How should patients prepare for radiology and ultrasound procedures?",{"text":118,"@type":110},"The form lists exam-specific preparation steps such as fasting timeframes, fluids restrictions, and special instructions for ultrasound (e.g., water intake for renal ultrasound) and other listed radiology procedures.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},307765,1790558013,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":76,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":9},24464137899374,"https://us-avatar.wpscdn.com/davatar_3d24733baf745e90a7e4bdd5f77d97b2","| FAX COMPLETED ORDER TO 360-493-5236 |  |  |  |  |\n| --- | --- | --- | --- | --- |\n| PATIENT DATE OF BIRTH:  / / \u003Cbr>PATIENT’S FULL LEGAL NAME (LAST, FIRST, MIDDLE):  ORDERING PHYSICIAN / PROVIDER (Please Print):  SIGNS AND SYMPTOMS (ICD DXcode): \u003Cbr>____________________________________________________________________________________________\u003Cbr>Exam(s) ordered or pick from lists below:  \u003Cbr>* L.I.P. Signature:   TODAY’S DATE:  / /  TIME:  \u003Cbr>* If Doctor requests DI to call and schedule the patient , the following information is required: Patient Phone Number:   Insurance:   Authorization \\#:   RESULTS ROUTING:  Send CD  Patient to return with CD\u003Cbr>Phone report \\#:   Fax report \\#:   Additional Reports To:  \u003Cbr>ADDITIONAL INFORMATION FOR SCHEDULED STUDIES\u003Cbr>Relating Prior Exam?:  Yes  No - If Yes, where?   Recent Labs required for all contrast studies; i.e. CT’s, MRI’s, Angiograms, for patients 60 and over\u003Cbr>• Creatinine (fax copy with order):   Date Drawn:  / / \u003Cbr>• Does patient take Glucophage® or Metformin?  Yes  No\u003Cbr>• Does patient have known IV contrast allergy?  Yes  No\u003Cbr>• Patients weight:   (required for NM, CT’s, MRI’s and interventional studies)\u003Cbr>|  |  |  |  |\n| HEAD AND NECK  CPT\u003Cbr> Facial 3v 70150 | EXTREMITIES  CPT\u003Cbr> AC Joints Bil. 73050 | CAT SCAN  CPT\u003Cbr> Abd w/o 74150 | ULTRASOUND  CPT\u003Cbr>GENERAL | MRI / MRA  CPT\u003Cbr> Abd w/o (MRCP) 74181 |\n|  Mandible 4v+ 70110 |  Clavicle 73000 |  Abd w 74160 |  Abdomen 76700 |  Abdomen w / w/o 74183 |\n|  Nasal Bones 3v+ 70160 |  Shoulder 2v+ 73030 |  Abd w / w/o 74170 |  Abd. Ltd.-RUQ/GB 76705 |  Abd. MRAw / w/o 74185 |\n|  Orbits 4v+ 70200 |  Humerus 2v+ 73060 |  Abd / Pel. w/o 74176 |  Appendix 76705 |  Pelvis w/o 72195 |\n|  Sinus 3v+ 70220 |  Elbow 2v 73070 |  Abd / Pel. w 74177 |  Echocardiogram with |  Pelvis w / wo 72197 |\n|  Sinus 1-2v 70210 |  Elbow 3v+ 73080 |  Abd / Pel. w / w/o 74178 | Definity if indicated 93307 |  Brain wo 70551 |\n|  Skull 4v+ 70260 |  Forearm 2v 73090 |  Cervical w/o 72125 |  Guidance 76942 |  Brain w / w/o 70553 |\n|  SFT Neck 70360 |  Wrist 3v+ 73110 |  Chest w/o 71250 |  Renal 76770 |  Brain MRA w/o 70544 |\n| CHEST / ABDOMEN\u003Cbr> Chest 1v 71010\u003Cbr> Chest 2v 71020\u003Cbr> Ribs Unil 2v 71100\u003Cbr> Ribs Bil 3v 71110\u003Cbr> Abd. (KUB) 1v 74000\u003Cbr> Abd. 2v 74020\u003Cbr> Acute Abd. 1v CXR74022 |  Hand 3v+ 73130 |  Chest w 71260 |  Testicular 76870 |  Neck MRAw / w/o 70549 |\n|  |  Fingers 2v+ 73140 |  Chest w / w/o 71270 |  Thyroid / Neck 76536 |  C-Spine w/o 72141 |\n|  |  Hip 2v+ 73510 |  Head w/o 70450 | OB / GYN |  C-Spine w / w/o 72156 |\n|  |  Femur 2v 73550 |  Head w / w/o 70470 |  Biophysical Profile 76819 |  T-Spine w/o 72146 |\n|  |  Knee 1-2v 73560 |  KUB (stones) 74150 |  Obstetrical 76805 |  T-Spine w / w/o 72157 |\n|  |  Tibia Fibula 2v 73590 |  Lumbar w/o 72131 |  OB w/TVS 76805 |  L-Spine wo 72148 |\n|  |  Ankle 3v+ 73610 |  Maxillofacial w/o 70486 | + 76817 |  L-Spine w / w/o 72158 |\n|  |  Foot 3v+ 73630 |  Orbits w/o 70480 |  Pelvis w/TVS 76856 | Extremities w/ jnt w/o |\n|  |  Toes 2v+ 73660 |  Pelvis w/o 72192 | + 76830 | Hip/knee/ankle 73721 |\n| SPINE / PELVIS |  Infant Lower Ext.73592 |  Pelvis w 72193 | Arterial Doppler: | Shoulder,wrist   73221 |\n|  Cervical 2 or 3v 72040 | UROLOGY |  Pelvis w / w/o 72194 |  Carotid Duplex 93880 | Extremities w/jnt w/cont |\n|  Lumbar 2 or 3v 72100\u003Cbr> Pelvis 1 or 2v 72170\u003Cbr> Sacrum/Coccyx 72220\u003Cbr> SI Joints 2v 72200\u003Cbr> T-L Junction 72080\u003Cbr> Thoracic 2v 72070\u003Cbr> Epi Cerv / Thor 62310\u003Cbr> Epi Lumb / Sac 62311\u003Cbr> Facet Cerv / Thor 64490\u003Cbr> Facet Lumb / Sac 64493\u003Cbr> Nerve Root C-T 64479 |  VCUG 74455\u003Cbr>GASTRO / FLUORO\u003Cbr> Be Enema 74270\u003Cbr> Be w/air 74280\u003Cbr> Dysphagia 74230\u003Cbr> Esoph 74220\u003Cbr> Small Bowel 74250\u003Cbr> UGI 74240\u003Cbr> UGI w/SB 74245 |  Sinuses 70486\u003Cbr> Sinus Ltd. 70486-52\u003Cbr> ST Neck w/o 70490\u003Cbr> Temporal Bones 70480\u003Cbr> Thoracic w/o 72128\u003Cbr>CTA’s\u003Cbr> Abd. 74175\u003Cbr> [Abd. w/ Ext. run 75635](Abd. w/ Ext. run 75635)\u003Cbr> Chest 71275\u003Cbr> Head 70496\u003Cbr> Neck 70498 |  mesenteric Art. 9397","cbCaieVKCMR7XKAG","https://ap.wps.com/l/cbCaieVKCMR7XKAG","pdf",170316,"English","# Patient Order Information\n## Patient details and ordering physician\n## Exam selection and scheduling fields\n## Additional information for scheduled studies\n\n# Imaging Exam Categories (with CPT codes)\n## Head and neck\n## Extremities\n## Cat scan and MRI/MRA\n## Ultrasound and OB/GYN\n## Spine/pelvis and urology\n## Gastro/fluoro and CT angiography\n## Doppler studies\n## Nuclear medicine options\n\n# Department Contact and Exam Preparations\n## Scheduling office contact and arrival guidance\n## Radiology preparation\n## Ultrasound preparation","[{\"question\":\"Where should the completed order be faxed?\",\"answer\":\"Fax the completed order to 360-493-5236, as indicated on the form.\"},{\"question\":\"What information is required for the scheduled study section?\",\"answer\":\"The form requests prior-exam relation details, recent labs for contrast studies, creatinine date and faxed copy, medication/contrast allergy status, and patient weight for specified exams.\"},{\"question\":\"How should patients prepare for radiology and ultrasound procedures?\",\"answer\":\"The form lists exam-specific preparation steps such as fasting timeframes, fluids restrictions, and special instructions for ultrasound (e.g., water intake for renal ultrasound) and other listed radiology procedures.\"}]","Providence St. Peter Hospital Diagnostic Imaging Department - Completed Order Form - Fax Completed Order to 360-493-5236 | PDF",1789854680]