CT Order
Scheduling Options:
Fax completed form to (269) 342.8513
Call (269) 383.5593 to schedule patient
Give patient completed form and ask them
to call (269) 383.5593 to schedule
Name (Last)
Birth Date
(First)
Maiden or Previous Name
Borgess Brain & Spine Institute, Kalamazoo
Borgess – Westside, Kalamazoo
Borgess at Woodbridge Hills – North, Portage
Borgess-Pipp Hospital, Plainwell
Borgess-Lee Memorial Hospital, Dowagiac
Borgess Health Park, Battle Creek
(M.I.)
Sex
M
F
Physician
Phone
Appointment Date / Time
Consultant Copy To
Phone
Narrative Diagnosis Code Description
Patient Address
Any previous studies
Please add additional data for interpretation purposes
To assist with scheduling, please check all that apply:
History of allergy to contrast
Asthma
Kidney problems
Diabetes
Hypertension
Pregnant
If yes, which trimester: 1
2
CT exams with and/or without contrast will be performed per Radiologist’s protocol.
If you would NOT like contrast administered, check this box:
Please explain:
3
CT ANGIOGRAPHY
CTA Angio Head
CTA Angio Neck
CTA Angio Upper Extremity
CTA Angio Lower Extremity
CTA Angio Abdomen/Aorta
CTA Angio Chest/Aorta
CTA Angio Pelvis
CTA Mesenteric ischemia
CTA Angio Chest w/Pulmonary Embolism Protocol
CTA Angio Chest w/Pulmonary Vein Protocol
CTA Angio Endograft Protocol
CTA Coronary Arteries
CT Calcium Scoring
CT Appendicitis Protocol
CT Pancreatic Protocol
CT IVP Protocol
CT Liver Mass Protocol
CT Renal Stone Protocol
CT Renal Mass Protocol
CT Enteroclysis
CT Colonography
CT Brain
CT Maxillofacial
CT Maxillofacial (Sinus)
CT Orbit, IACs, Pituitary
Specific Protocol Studies
CT SPINE
CT Cervical Spine
CT Thoracic Spine
CT Lumbar Spine (LS / lumbosacral)
CT Chest/Thorax
CT Abdomen
CT Pelvis
CT Shoulder
L
R
CT Scapula
L R
CT Upper Arm (Humerus)
L R
CT Elbow
L R
CT Lower Arm (Radius/Ulna)
L R
CT Wrist
L R
CT Hand
L
R
CT Arthrogram w/Fluoroscopically B
L R ______________
with only
assisted Radiographic Injection Call Scheduling at 383.5593
CT Hip
L
R
CT Upper Leg (Femur/Thigh)
L R
CT Knee
L R
CT Lower Leg (Tibia/Fibula)
L R
CT Ankle (including Achilles)
L R
CT Foot
L R
CT Arthrogram w/Fluoroscopically B
L R ______________
with only
assisted Radiographic Injection Call Scheduling at 383.5593
CT CHEST, ABDOMEN, PELVIS
CT UPPER EXTREMITY
CT LOWER EXTREMITY
CT HEAD
OTHER CT EXAMS
CT Stereotactic:
CT Soft Tissue Neck
CT Brachial Plexus
Other:
L
_______________________________________________________________ , MD / DO
Physician Office: Please fax orders to (269) 276.8075.
White copy - BMC Yellow copy - physician office
721-1-19 Revised 10/15
R
Phone #
Call Report
Hold + Take
Hold Take Call Report
Important Patient Information
Instructions for Abdomen and/or Pelvis CT Scan
Your well being is our number one concern. Please review the
following information prior to your scan so we can assure you
receive the best possible service when you come to our facility.
• Beginning six hours prior to your scan, you may have nothing to
eat. You may have clear liquids until two hours prior to your scan.
Any oral medication after this time may be taken with a small
amount of water to digest them.
• You will receive a call from our nurse the day before your scan
to go over some important screening questions.
Gastrografin Prep
1.Mix the CT prep given to you with 24 oz. of any flavored liquid
or water. Do not use dairy products. Suggested mixes: juice,
koolaid, pop, etc.
2.Two hours prior to your scan, drink half (12 oz.) of the mixture.
3.One hour prior to your scan, drink the remaining half of the
mixture.
4.You will be asked to drink another 8 oz. of contrast when you
arrive for your scan.
• Please confirm at which location you are scheduled.
• Please arrive 20 minutes prior to your scan time.
• Please bring a current list of medications you are taking.
• If oral prep is required, please see instructions in right column.
Any other prep requirements will be explained by the nurse.
You can pick up the prep at:
Borgess Brain & Spine Institute
Borgess – Westside
Borgess at Woodbridge Hills
EZ Cat Prep
1.Mix bottle of EZ Cat with 16 oz. of any flavored liquid or water
to make a total of approximately 24 oz. of solution.
2.Two hours prior to your scan, drink half (12 oz.) of the mixture.
3.One hour prior to your scan, drink the remaining half of the
mixture.
4.You will be asked to drink another 8 oz. of contrast when you
arrive for your scan.
• Labs will be required if you are having IV contrast. Depending
on the results of your labs, hydration may be required. If
hydration is required, please be aware that you may be here
anywhere between 1-4 hours.
• Unless your physician or the radiologist indicates otherwise, an
IV will be started in a vein in your arm to infuse an IV contrast
during your scan to highlight the blood vessels in your abdomen
and pelvis.
Kalamazoo
as
Tex
Milham Rd.
Dr.
N
62
ling
131
W. Main St. (M-43)
Park St.
11th St.
9th St.
Dr.
Stadium
Westnedge Ave.
Borgess – Westside
6565 West Main Street, Kalamazoo, MI 49009
(269) 372.7459
(269) 372.5601 Fax
62
Borgess-Lee Memorial Hosptal
420 West High Street, Dowagiac, MI 39047
(269) 782.8681
(269) 783.3056 Fax
Battle
Creek
N
94
Capital Ave. SW
94
e St.
Portag
Oakland Dr.
Borgess Brain & Spine Institute
1541 Gull Road, Kalamazoo, MI 49048
(269) 383.5593
(269) 276.8075 Fax
Borgess–
Westside
Kalamazoo
.
l Rd
Gul
51
Cass
)
-43
. (M
l Rd
Gul
Riverview Dr.
g
kin
Par ucture
Str
Douglas Ave.
Bus
ines
s 13
1
N
Fro
nt
St.
51
BorgessLee
Memorial
Hospital
W. Division
W.
Ma
in
W.
Hig
hS
t.
Dowagiac
Lowe St.
fer
Borgess at Woodbridge Hills – North
7901 Angling Road, Portage, MI 49024
(269) 324.8400
(269) 324.8621 Fax
Riverview Dr.
W. Centre Ave.
Borgess at
Woodbridge Hills – South
Borgess-Pipp Hospital
411 Naomi Street, Plainwell, MI 49080
(269) 685.0746
(269) 685.0842 Fax
Paul St.
f
Sha
s
ges
Bor dical
Me nter
Ce
131
Plainwell
E. Bridge St. (M-89)
Douglas Ave.
ss ine
rge Sp
Bo ain & e
Br titut
Ins
Moorsbridge Rd.
Borgess at
Woodbridge Hills – North
Sprinkle Rd.
94
Romence Rd.
Oakland Dr.
12th St.
I-94
ge St.
Exit 80
(M-8
9)
BorgessPipp Hospital
Portage
131
Rd.
E. Main St.
BL
Porta
Westnedge Ave.
Oakland Dr.
N
ll R
Gu
King Hwy (M-96)
Park St.
Dr.
Stadium
oad
(M
N
Main St.
Naomi St.
W. Main St. (M-43)
43)
St.
Borgess
Medical
Center
Paterson St.
egan
St.
Ang
1
Otsego
All
N
94
ffer
s 13
N
Sha
ines
131
Riverview
Bus
Douglas Ave.
Exit 41
66
Borgess
Health Park
94
Beckley Rd. / B Dr. N
Borgess Health Park
3035 Capital Avenue SW, Battle Creek, MI 49015
(269) 565.9100
(269) 565.9101 Fax