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Podiatry Request Form

Patient First Name*
Patient Last Name*
Date of Birth*
MM slash DD slash YYYY
SYMPTOMS - CLINICAL INFO - REQUIRED BY INSURANCE CO.
- Chronic
- New Onset
- Follow-up
Referring Doctor
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Fax
Doctor's Signature*
Copy of Report to:
Name
Phone
Tax
PODIATRY IMAGING
Indications
- Achilles
- Coalition
- Foreign body
- Fracture
- impingement
- Infection: Cellulitis, Osteomyelitis
- Ligament/Tendon
- Mass/Neuroma
- Osteoporosis
- Pain
- Trauma
- Plantar Fascia
- Turf Toe/Plantar Plate
- Other
Other
X-Ray / Fluoroscopy
- Ankle
- Ankle Left
- Ankle Right
- Calcaneus
- Calcaneus Left
- Calcaneus Right
- Femur
- Femur Left
- Femur Right
- Foot
- Foot Left
- Foot Right
- Toes
- Toes Left
- Toes Right
- Hip
- Hip Left
- Hip Right
- Hip/Pelvis
- Knee
- Knee Left
- Knee Right
- Leg length survey
- Leg length survey Left
- Leg length survey Right
- Pelvis only
- Pelvis only Left
- Pelvis only Right
- Tibia / Fibula
- Tibia / Fibula Left
- Tibia / Fibula Right
- Weight bearing
- Weight bearing Left
- Weight bearing Right
Additional Views
BONE DENSITY
- DEXA
MRI
- Without Contrast - 73721
- With & Without Contrast- 73723
- Ankle/Hindfoot
- Ankle/Hindfoot Left
- Ankle/Hindfoot Right
- Achilles
- Achilles Left
- Achilles Right
- Midfoot
- Midfoot Left
- Midfoot Right
- Forefoot
- Forefoot Left
- Forefoot Right
- Tibia / Fibula
- Tibia / Fibula Left
- Tibia / Fibula Right
- Other
Other
CT
- Lower Extremity
- Without Contrast - 73700
- Without Contrast - 73700 Left
- Without Contrast - 73700 Right
- Lower Extremity
- With & Without Contrast - 73702
- With & Without Contrast - 73702 Left
- With & Without Contrast - 73702 Right
- 3D Reconstruction
- 3D Reconstruction Left
- 3D Reconstruction Right
- Ankle
- Ankle Left
- Ankle Right
- Foot
- Foot Left
- Foot Right
- Scan-o-gram
- Scan-o-gram Left
- Scan-o-gram Right
- Other
Other
ULTRASOUND
- Extremity Venous
- Extremity Venous Left
- Extremity Venous Right
- Extremity Venous Unilateral 93971
- Extremity Venous Bilateral 93970
- Extremity Arterial
- Extremity Arterial Left
- Extremity Arterial Right
- Extremity Arterial Unilateral 93926
- Extremity Arterial Bilateral 93925
- Lower Extremity
- Non-Vascular
- Non-Vascular Left
- Non-Vascular Right
- Non-Vascular Unilateral 76881
- Soft Tissue
- Soft Tissue Left
- Soft Tissue Right
- Soft Tissue Unilateral 76882
- Plantar Fascia
- Plantar Fascia Left
- Plantar Fascia Right
- Plantar Fascia Unilateral 76882
- Achilles
- Achilles Left
- Achilles Right
- Achilles Unilateral 76882
- PTT Flexor Tendons
- PTT Flexor Tendons Left
- PTT Flexor Tendons Right
- PTT Flexor Tendons Unilateral 76882
- Peroneal Tendons
- Peroneal Tendons Left
- Peroneal Tendons Right
- Peroneal Tendons Unilateral 76882
- Neuroma
- Neuroma Left
- Neuroma Right
- Neuroma Unilateral 76882
- Plantar Plate
- Plantar Plate Left
- Plantar Plate Right
- Plantar Plate Unilateral 76882
- Tibialis anterior/extensor tendons
- Other
Other
ULTRASOUND-GUIDED INJECTIONS
- Joint
- Tendon Sheath
- Morton’s Neuroma
- Plantar Fascia
- Retrocalcaneal Bursa
- Tibial Nerve/Tarsal Tunnel
- Other
Joint (please specify)
Tendon Sheath (please specify)
Morton’s Neuroma (please specify)
Other

ACCREDITED BY THE AMERICAN COLLEGE OF RADIOLOGY FOR EXCELLENCE

AMERICAN COLLEGE OF RADIOLOGY FOR EXCELLENCE

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