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Patient Phone (Day): Physician Signature: q PACSCube CD-Rq CareGate Clinical Information/ Diagnosis: q Send CD by courier q Send CD w/patientq Call physician w/appt time q Fax physician w/appt time Are you aware if the patient has M. Tuberculosis: q YES q NO q Call if patient reschedules Does your patient have a pacemaker: q YES q NOAppointment Date and Time: IV Contrast used at the discretion of the radiologist unless otherwise indicated.
Send copy of report to: q CT (including, at the discretion of the radiologist, 3D reconstruction and plain films of requested area unless otherwise indicated) q Physician contact number for q CTA (including, at the discretion of the radiologist, plain films of requested area unless urgent findings: otherwise indicated) q After-hours/weekend #: q MYELOGRAM/CT (including, 3D reconstruction if indicated) Please specify site(s): q MRI (including, at the discretion of the radiologist, 3D reconstruction, plain films of Patients should arrive fifteen minutes requested area, and/or orbits unless otherwise indicated) prior to appointment time. Detailed information about your exam is q MRA (including, at the discretion of the radiologist, plain films of requested area, provided in the Southwest Diagnostic and/or orbits unless otherwise indicated) Imaging Center patient brochure and q MRI Arthrogram (including, at the discretion of the radiologist, plain films of requested area, and/or orbits unless otherwise indicated) Women during childbearing ages (12-55) should be screened for the q Ultrasound (including, at the discretion of the radiologist, 3D imaging unless otherwise indicated) possibility of pregnancy before scheduling Diagnostic, CT, and/or MRI q Diagnostic Mammogram (Possible Breast Ultrasound if Indicated)q Special Views Diagnostic Mammogram (Possible Breast Ultrasound if Indicated) Payment is required at the time of q Breast Screening Mammogram service unless other arrangements have been made.
q Bone Densitometry (DEXA)q Diagnostic Radiology Examination Desired: FOR PREPARATIONS, PLEASE SEE Presbyterian Professional Building 3 (PB3) Phone 214/345-6905 8230 Walnut Hill Lane, Suite 100 and 102 Dallas, TX 75231-4472 Phone 214/345-4331 Please park in lot #5 (open parking).
Parking validation will be provided.
WHITE – Patient Copy to Bring to SWDIC YELLOW – Referring Physician's Office for EXAM PREPARATIONS These preparations must be followed completely to ensure accurate test results.
 1. BARIUM ENEMA (BE)*: Bowel preparation kits Evac-Q-Kwik or Tridrate Bowel Evacuant Kit may be purchased over the counter from a pharmacy. These kits include the following: Magnesium Citrate Oral Solution, Bisacodyl tablets, and a Bisacodyl suppository. (The contents can all be purchased individually if the kits are not available at your pharmacy.) Please refer to the separate "Colon Preparation Instructions" sheet from us for specific instructions. Beginning at noon the day before your exam have a clear liquid lunch and dinner. At 7 p.m. drink entire 10 oz. bottle of Magnesium Citrate, followed by 10 oz. of clear fluids. At 9 p.m. take the 3 Bisacodyl tablets. On the day of your exam, insert the suppository three hours before the exam.
 2. BARIUM ENEMA WITH INTRAVENOUS PYELOGRAM (IVP): Same as above.
 3. CT SCAN: Please inform the scheduler if you are allergic to Iodine, have impaired kidney function, or are taking oral medication to control your diabetes. It is very important that we speak with you prior to your exam so the radiologist can review your medical history before you arrive. IF WE ARE UNABLE TO REACH YOU BY 3PM THE DAY BEFORE YOUR EXAM, PLEASE CALL OUR CONFIRMATIONS DEPARTMENT AT (214)345-7035 OR YOUR APPOINTMENT MAY NEED TO BE RESCHEDULED. Do not eat or drink 3 hours prior to your exam time.
 3a. CT SCAN (abdomen): See above #3. Please arrive 45 min. early to receive the contrast agents for your exam.
 3b. CT SCAN (abdomen and pelvis): See above #3. Please arrive 11/4 hours early to receive the contrast agents for your exam.
 3c. CT SCAN (head, neck, chest, spine): See above #3. Please arrive 15 minutes prior to exam time.
 4. ESOPHAGRAM (barium swallow): No preparation necessary if not being done with another procedure.
 5. INTRAVENOUS PYELOGRAM (IVP) (kidneys): 4 p.m. day prior to exam take 10 oz. of Magnesium Citrate, followed by 10 oz. of clear liquids (bouillon, broth, apple juice, grape juice) or 4 oz. of plain flavored gelatin (no cream or fruit). You may have water or liquids as desired during the evening. On the day of the exam you may have 8 oz. of clear liquids (bouillon, broth, apple juice, grape juice). Avoid carbonated beverages. Do not eat, drink, chew gum, or smoke four hours prior to your exam time. Please inform Scheduling if allergic to iodine or if taking the medications Glucophage, Glucovance, Metformin, Avandamet, or Metaglip.
 6. MRI SCAN: It is very important that we speak with you prior to your exam so the radiologist can review your medical history before you arrive. IF WE ARE UNABLE TO REACH YOU BY 3PM THE DAY BEFORE YOUR EXAM, PLEASE CALL OUR CONFIRMATIONS DEPARTMENT AT (214)345-7035 OR YOUR APPOINTMENT MAY NEED TO BE RESCHEDULED. Do not wear makeup, hairpins, jewelry, or barrettes for this exam. You will be asked to change into a gown. If you are claustrophobic, please inform the person taking your medical history so the radiologist can prescribe a mild sedative. If you require sedation, please arrive 11/4 hours early. For your safety, someone needs to stay with you and drive you home following your exam.
 6a. MRI SCAN (abdomen): See above #6. Do not eat or drink 3 hours prior to your exam time.
 7. MAMMOGRAM: Please wear a two-piece outfit so that you only have to undress from the waist up. It would be preferable to schedule a mammogram when breasts are less tender (5-10 days after the start of menstrual cycle).
 8. MYELOGRAM: Nothing to eat three hours prior to exam time. You may have water or liquids as desired. Please wear loose fitting garments that do not contain metal objects, such as clasps, zippers, etc. For your safety and comfort, you must have someone accompany you during the procedure and drive you home. For 24 hours following the exam, you will be on strict  9. PLAIN FILMS OF REQUESTED MRI AREA: As deemed necessary by the radiologist. This examination is frequently requested in coordination with the MRI.
 10. SMALL BOWEL: Do not eat or drink after midnight prior to the day of a morning exam. Please do not schedule this exam after 1:00pm.
 11. ULTRASOUND – ABDOMEN (liver, gallbladder, pancreas, kidneys, aorta, spleen, or abdominal Doppler study): Nothing to eat or drink (except water) for eight hours prior to exam. You may take medications. Note: Please schedule renal sonograms with Doppler in the mornings.
 12. ULTRASOUND – ABDOMEN WITH PELVIS: Nothing to eat or drink (except water) for eight hours prior to exam. You may take medications. One hour prior to the first ultrasound exam, begin drinking 32 oz. of water. Finish drinking all water in 15 minutes. (Water must be finished 45 minutes prior to time of exam.) DO NOT VOID after drinking the 32 oz. of water. The bladder must be full for the exam.
 13. ULTRASOUND – ABDOMEN WITH UPPER GI: Same instructions as Upper GI (#18).
 14. ULTRASOUND – PELVIS, HYSTEROSONOGRAM, OB LIMITED (under 14 weeks), or OB COMPLETE (over 14 weeks): One hour prior to exam time, begin drinking 32 oz. of water. Finish drinking all water in 15 minutes. (Water must be finished 45 minutes prior to time of exam.) DO NOT VOID after drinking the 32 oz. of water. The bladder must be full for the exam.
 15. ULTRASOUND – RENAL (or Kidney): No preparation necessary. For RENAL ULTRASOUND WITH DOPPLER – See Ultrasound - Abdomen prep (#13).
 16. ULTRASOUND – RENAL/BLADDER: 1 hour prior to appointment time, begin drinking 24 oz. of water. Finish in 15 minutes.
DO NOT VOID. Bladder must be full for exam.
 17. ULTRASOUND – THYROID, NECK, BREAST, SCROTUM, APPENDIX, HERNIA or EXTREMITY: No preparation necessary.
 18. UPPER GI (UGI): The night before your exam, eat a light supper. Limit meal to items such as a small sandwich, flavored gelatin, soup, or broth. After midnight, do not have anything else to drink or eat until after your exam. This includes no smoking, chewing gum, or eating hard candy.
 19. UPPER GI AND SMALL BOWEL (combined): Same as Upper GI (#18) above.
 20. VIRTUAL COLONOSCOPY: Please call scheduling department for instructions.
ATTENTION: FOR CHILDREN AND EXTREMELY ELDERLY OR DEBILITATED PATIENTS, YOU MAY WISH TO CONSULT A RADIOLOGIST OR YOUR PHYSICIAN REGARDING PREPARATIONS.

Source: https://swdic.com/files/exam-requisition.pdf