MRI/CT Referral Form

Referring physician offices can now upload patient records when submitting web referrals. Click link on the bottom of the page to upload records and orders.

Contact Information

Please note, the report will be faxed to the number listed below.

Contact Person
Phone Number
Fax Number
Email*

Patient Information

First Name
Middle Initial
Last Name
Date of Birth (mm/dd/yyyy)
Sex Male Female
SSN
Home Address
City
State
Zip
Home Number
Cell/Daytime Number

Primary Insurance Information

Insurance
Insurance Authorization*
Insured
(if different from patient)
SSN
Member ID#
Group #
Billing Address

Secondary Insurance Information

Insurance
Insured
(if different from patient)
SSN
Member ID#
Group #
Billing Address

Prescription/Order

Reason for exam/Symptoms
Rule Out
Diagnosis Code/Description
Physician Name
NPI#

Report /CD Request

Report Routine
Urgent
Call Report (Phone: )
Fax Report (Fax: )
Send CD To referring physician
To referring physician with patient

MRI – Siemens 1.5T

FONAR Upright
Multi-Positional MRI

CT

Brain
Pituitary
IAC
Soft Tissue Neck
Orbits
Spine, Cervical
Spine, Thoracic
Spine, Lumbar
Pelvis
  Brachial Plexus Left Right
  Hip Left Right
  Knee Left Right
  Ankle Left Right
  Foot Left Right
  Shoulder Left Right
  Elbow Left Right
  Wrist Left Right
  Hand/Finger Left Right
Other (specify):
Arthrogram
Add Contrast (IV)
  If needed
No
Yes (with & without)
*All contrasted studies require a Creatinine and GFR
Brain
Pituitary
IAC
Cervical Spine Upright
Cervical Flexion/Extension
Thoracic Spine - Upright
Lumbar Spine - Upright
Lumbar Flexion/Extension
Pelvis
 
  Hip Left Right
  Knee Left Right
  Ankle Left Right
  Foot Left Right
  Shoulder Left Right
  Elbow Left Right
  Wrist Left Right
 
Other (specify):
 
Add Contrast (IV)
  If needed
No
Yes (with & without)
*All contrasted studies require a Creatinine and GFR
Head
Facial Bones
Sinuses Screening (limited)
Sinuses Intermediate (coronals)
Sinuses Full (axial & coronal)
Temporal Bones
Neck Soft Tissue
Spine
Cervical
Thoracic
Lumbar
Extremity
Pelvis
Left
Right
Other
Add Contrast (IV)
  If needed
No
Yes (with & without)
*All contrasted studies require a Creatinine and GFR
Click Here To Attach Patient Records
(PDF, DOC/DOCX and JPG file types accepted)

Thank you for your referral. If you are unable to upload office notes, please fax all office visit notes, labs, diagnostic reports and any other records to our office at 919-281-1885. Once the records are received we will contact the patient to schedule the appointment.

"Being able to access your Orthopedic Urgent Care on a Saturday was a God-send. It was wonderful to avoid an ER. Thank you all so much for being open on Saturdays and after hours, Monday through Friday."

EmergeOrtho of the Triangle. All Rights Reserved. All trademarks and registered trademarks are of their respective companies. | Sitemap
EmergeOrtho complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.
EmergeOrtho does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Notice of Non-Discrimination | Limited English Proficiency