Appointment for Diagnostic Imaging - Vantage · 2008-11-05 · Valley Diagnostic Imaging Services-...
Transcript of Appointment for Diagnostic Imaging - Vantage · 2008-11-05 · Valley Diagnostic Imaging Services-...
![Page 1: Appointment for Diagnostic Imaging - Vantage · 2008-11-05 · Valley Diagnostic Imaging Services- Olympic Building is located on the back of the campus facing West. CT: A CT, computerized](https://reader034.fdocuments.net/reader034/viewer/2022042309/5ed57b690bd3843450408b6c/html5/thumbnails/1.jpg)
Will a dental stent be provided? Yes No
Appointment for Diagnostic Imaging Exam Date: ________ Check-in Time: ________
Patient Information:Name: _______________________________________ Phone: ______________ SSN: ___________
Insurance: ____________________________________________ Date of Birth: _____/_____/_____Please bring this form and your medical and dental insurance billing information.
Exam Information:Exam Ordered:
CT Maxilla $375CT Mandible $375CT Mandible and Maxilla $750
Clinical:
425.656.5550 ph. See map and directions on back 425.656.5552 fax
ImagesDICOMM format CDFilms
Simplant View CD:_______________________Other__________________________________
Simplant CDSimplant CD w/1xSoftware ($200 One-shot)
Fax Final reportMail/ Courier Final report
Referring Doctor Signature: __________________________________________________________
Physician Information:Referring Doctor: ____________________________ Phone: _______________ Fax: ______________
Next Appointment with the Doctor: ______________________________________________________Planning Software Used: Simplant Nobel Guide VIP None Other: _______________
Report/ Image Preference:Reports
Phone Prelim reportFax Prelim reportCC to Dr: ________________________________
733.03 Evaluate for Disuse Osteoporosis733.7 Evaluate for Disuse Atrophy478.19 Pneumatization of the Sinus733.99 Evaluate for Foreign Body in the bone526.4 Inflammation of the Jaw (Abscess,Osteomyelitis, Sequestrum)521.4x - Evaluate for bone resorption
526.5 Alveolitis of the Jaw (Infection in thetooth socket)733.01Osteoporosis, post-menopausal793.0 Abnormal findings on radiologic exam,head/skullOther/Signs/Symptoms:_________________________________________________________
![Page 2: Appointment for Diagnostic Imaging - Vantage · 2008-11-05 · Valley Diagnostic Imaging Services- Olympic Building is located on the back of the campus facing West. CT: A CT, computerized](https://reader034.fdocuments.net/reader034/viewer/2022042309/5ed57b690bd3843450408b6c/html5/thumbnails/2.jpg)
400 S. 43rd St, Renton, WA 98055 •• 425.656.5550 Ph. •• 425.656.5552 Fax •• www.vrads.com
Valley Radiologists, Inc. P. S. in association with Valley Medical Center
Directions from the North: From Hwy. 167 take SW 41st Street exit Take a left onto E. Valley Road Take a left onto SW 43rd Street Take a left onto Talbot Road South Take a left into 3rd driveway on the left. Follow down the hill and around the back of the Valley Medical Center campus
Valley Diagnostic Imaging Services- Olympic Building is located on the back of the campus facing West.
CT:A CT, computerized tomography scan is a special examination in which multiple “slices” or pictures are taken through an area of the body. You will be placed on a table which will move you into the scanner. After each “slice” is taken the table will move a small distance to take the next picture. CT scanning for dental imaging is non-invasive and takes less than 30 minutes. Actual exam time is approximately 10 minutes.
CT Preparation: No preparation necessary. Please bring your dental stent if it was provided to you by your referring physician.
Directions from the South: From Hwy. 167 take SW 43rd St. exit Take a right onto SW 43rd St. Take a left onto Talbot Road South Take a left into 3rd driveway on the left. Follow down the hill and around the back of the Valley Medical Center campus
Valley Diagnostic Imaging Services- Olympic Building is located on the back of the campus facing West.