CALL 800-626-8315, FAX 800-650-0615, OR EMAIL SCHEDULING@ARCHRAD.COM TO SCHEDULE AN APPOINTMENT

Appointment Date_______________________________ Appointment Time__________________________________________

Patient Name____________________________________ Phone #__________________________________________________

Report to additional physician(s)_____________________________________________________________________________

Clinical History/Diagnosis___________________________________________________________________________________

Referring Physician________________________________________________________________________________________

Referring Physician Signature________________________________________________________________________________

Phone#_________________________________Fax#______________________________E-mail__________________________

EXAMINATION TYPE:                              X-RAY                         ULTRASOUND/ECHO                          ULTRASOUND GUIDED PROCEDURE

BODY PART:  ________________________________________________________________________________________________________________________________

ICD-9 CODE & HISTORY:  ______________________________________________________________________________________________________________________

Special Instructions ___________________________________________________________________________________________________________________________

EXAMINATION TYPE:                              X-RAY                         ULTRASOUND/ECHO                          ULTRASOUND GUIDED PROCEDURE

BODY PART:  ________________________________________________________________________________________________________________________________

ICD-9 CODE & HISTORY:  ______________________________________________________________________________________________________________________

Special Instructions ___________________________________________________________________________________________________________________________

EXAMINATION TYPE:                              X-RAY                         ULTRASOUND/ECHO                          ULTRASOUND GUIDED PROCEDURE

BODY PART:  ________________________________________________________________________________________________________________________________

ICD-9 CODE & HISTORY:  ______________________________________________________________________________________________________________________

SPECIAL INSTRUCTIONS:  _____________________________________________________________________________________________________________________

EXAMINATION TYPE:                              X-RAY                         ULTRASOUND/ECHO                          ULTRASOUND GUIDED PROCEDURE

BODY PART:  ________________________________________________________________________________________________________________________________

ICD-9 CODE & HISTORY:  ______________________________________________________________________________________________________________________

SPECIAL INSTRUCTIONS:  _____________________________________________________________________________________________________________________

Link to Common ICD-9 Codes for Ultrasound – http://archrad.com/icd9-ultrasound.html

Link to Common ICD-9 Codes for X-Ray – http://archrad.com/icd9-xray.html

• referral-form
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• referral form, schedule radiology online, schedule x-ray, schedule ultrasound, ultrasound scheduling
• Referral form to schedule x-ray, ultrasound, MRI scan, CT scan, or mammography in los angeles.
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