tampa’s first imaging center of excellence · tampa bay old old tampa bay hillsborough bay 275 c...
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Patient Name: __________________________________________________________________ DOB: ______________________
Phone: ( ) - ____________________________ Allergies: qNKA ____________________
Diagnosis or Signs/Symptoms: 1._____________________________ 2. __________________________ 3. _______________________ ___
Ordering Please Physician OrderPhysician Print ________________________________ Signature ________________________________ Date ______________
PET/CT BREAST IMAGING
o PET/CT / Restagingo PET/CT / Evaluation to Therapy Response
Scheduling: (813) 874.3177 Fax: (813) 879.1809qTower Breast Diagnostic Center - Northside • 2716 University Square Dr.qTower Breast Diagnostic Center - Habana • 4719 N. Habana Ave.qTower Radiology Center - BBD • 3069 Grand Pavilion Dr.qTower Radiology Center - South Tampa • 2106 S. Lois Ave.qTower Radiology Center - Carrollwood • 14499 N. Dale Mabry Hwy., Ste. 150qTower Radiology Center -Wesley Chapel • 2324 Oak Myrtle LaneqTower Radiology Center - North Dale Mabry • 17503 N. Dale Mabry Hwy.qBloomingdale Radiology Center - Bloomindale • 3350 Bell Shoals RoadqCommunity Diagnostic Center - Brandon • 500 Vonderburg Dr., W. Tower, Ste. 111
BREAST MRI
o Breast MRI w/ & w/o contrast - Bilateral Diagnostico Breast MRI w/o contrast - Implant (Rupture)
BREAST BIOPSY
o Radiologist To Determine Guidance Method o Stereotactic Breast Biopsy R / L o Ultrasound Breast Biopsy R / L o MRI Breast Biopsy R / L
PELVIC MRI
o Pelvic MRI w/ & w/out contrast - Uterine Fibroido Pelvic MRI w/o or w/ & w/o contrast - Routineo Pelvic MRI w/o contrast - Dynamico Pelvic MRI w/o contrast - Fetal
BONE DENSITY
o DEXA SCAN ______________________________________o Vertebral Fracture Assessment o Body Composition
MAMMOGRAPHY• Please Note: Screenings Are For “No Breast Problems” Only• We ask that you bring any and all previous mammography
films with you at the time of your exam.
o Bilateral Digital Screening w / CAD and Bone Density/ DEXAo Bilateral Digital Screening w / CADo Bilateral Digital Diagnostic w / ultrasound (if necessary)o Unilateral Digital Diagnostic w / ultrasound (if necessary) R / Lo Additional ViewsIMPLANTS? o Yes o NoDOES THE PATIENT HAVE PREVIOUS FILM? o Yes o No
(First) (MI) (Last)
ULTRASOUND
o Breast o R o L If palpable mass, please indicate location: ______________o Transvaginalo Pelvico Pelvic Sono o With transvaginal if necessaryo OB Transabdominalo OB Transvaginal o OB Limited o OB Completeo Other __________________________________
o Other:
Appt. Date:___________________ Time:_________ A.M. P.M
For your convenience, you can also request an appointment online. To request anappointment, log onto www.TowerRadiologyCenters .com/appointmentrequest
EXAM PREPS AND MAP ON REVERSE SIDE
SERVICES MAY VARY BY LOCATION
q CC: Report To: ________________________
Rev. 2/12
Tampa’s First Imaging Center of Excellence
*ACR accreditations vary by modality
Designated by the American College of Radiology
MAMMOGRAPHY PATIENTS BEFORE YOU ARRIVE FOR YOUR EXAM:
• We strongly recommend that you bring any and all previous mammography and or ultrasound films with youat the time of your exam. These previous films will be used for comparison.
• If you must have your films delivered, please arrange for them to arrive at the facility at least 2 days priorto your appointment.
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Gulf of Mexico
NORTH
Tampa Bay
Old Old TTampa Bayampa Bay
HillsboroughHillsboroughBay
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TOWER Radiology CenterNorth Dale Mabry
17503 N. Dale Mabry Hwy.813.968.4540
TOWER Radiology CenterCarrollwood
Sport & Orthopedic Radiology Centerat Tower
14499 N. Dale Mabry Hwy.Suite 150
813.968.6998
TOWER Diagnostic Center1916 Highland Oaks Blvd.
813.909.7476
TOWER Radiology CenterWesley Chapel
2324 Oak Myrtle Lane813.751.0422
Within Cypress Creek Development
TOWER OpenScan MRIPalms
14525 Bruce B. Downs Blvd.813.972.0669
TOWER Breast Diagnostic Center - Northside2716 University Square Drive
813.971.2050
TOWER Radiology Center - HabanaBreast Diagnostic Center - Habana
4719 N. Habana Ave. 813.874.7000
TOWER Radiology Center - South Tampa2106 S. Lois Ave.
813.288.8839
TOWER Radiology CenterBruce B. Downs
3069 Grand Pavilion Dr.813.977.9777
Bloomingdale Radiology Center3350 Bell Shoals Road
813.654.4883
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Community Diagnostic Center of Brandon500 Vonderburg DriveWest Tower, Suite 111
813.654.5400
JOHN
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PARS
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Fax: (813) 879-1809
INSTRUCTIONS & PREPARATION:NPO: Nothing By Mouth
Please arrive 20 to 30 minutes prior to your scheduled appointment so that you will have time to fill out the necessary paperwork.
MAMMOGRAPHY:Do not use deodorant, perfume, or dusting powder before having your mammogram.BREAST BIOPSY:(Instructions for Stereotactic, Ultrasound and MRI)Arrive 1 hour prior to procedure. NPO 2 hours before exam (3 hours for MRI Guided Biopsy). No aspirin, fishoil, Vitamin E or aspirin containing products 7 days before and 2 days after procedure. You may take Tylenol.If you are on blood thinners (Coumadin, Plavix, etc.), contact our biopsy coordinator (813) 971-2050 ext. 236. Wear a two piece, comfortable, loose fitting outfit with a sports bra or bra without underwire. A bra is required.BREAST MRI:Bilateral Diagnostic: NPO 3 hours before exam. No estrogen or hormone replacement therapy (medication forHot Flashes ONLY) for 4 weeks prior to exam. Continue all other hormones (example: For Chemotherapy,Thyroid Disease, Birth Control, etc...). Implants: (Rupture) NPO 3 hours before exam. PELVIC MRI:Routine: NPO 3 hours before exam. Dynamic: Water ONLY 3 hours prior to exam.Fetal: NPO 3 hours before exam.ULTRASOUND:Pregnancy/Pelvic Sonogram: You must begin drinking about 1 hour prior to your exam time. Drink at least 32 ounces of liquid, stay away from caffeine drinks, over this time period. DO NOT go to the rest room; you must have a full bladder for your exam.DEXA SCAN:Please wear comfortable clothes, however refrain from wearing any metal accessories (i.e. zippers, buttons, etc.). No other preparation is necessary.
IMPORTANT - PLEASE NOTEAny woman who is pregnant or thinks she might be pregnant should let the technologist or doctor know before beginning her exam. If you need driving directions, log onto www.towerdiagnostic.com and click on the facility locations. Find the facility and click on “driving directions”.