Patient Name: __________________________________________________________________ DOB: ______________________

Phone: ( ) - ____________________________ Allergies: qNKA ____________________

Diagnosis or Signs/Symptoms: 1._____________________________ 2. __________________________ 3. _______________________ ___

Ordering Please Physician OrderPhysician Print ________________________________ Signature ________________________________ Date ______________

PET/CT BREAST IMAGING

o PET/CT / Restagingo PET/CT / Evaluation to Therapy Response

BREAST MRI o Breast MRI w/ & w/o contrast - Bilateral Diagnostic o Breast MRI w/o contrast - Implant (Rupture)

BREAST BIOPSY

o Radiologist To Determine Guidance Method o Stereotactic Breast Biopsy R / L o Ultrasound Breast Biopsy R / L o MRI Breast Biopsy R / L

PELVIC MRI

o Pelvic MRI w/ & w/out contrast - Uterine Fibroido Pelvic MRI w/o or w/ & w/o contrast - Routineo Pelvic MRI w/o contrast - Dynamico Pelvic MRI w/o contrast - Fetal

BONE DENSITY

o DEXA SCAN ______________________________________o Vertebral Fracture Assessment o Body Composition

MAMMOGRAPHY• Please Note: Screenings Are For “No Breast Problems” Only• We ask that you bring any and all previous mammography films with you at the time of your exam. o Bilateral Digital Screening w / CAD and Bone Density/ DEXA o Bilateral Digital Screening w / CADo Bilateral Digital Diagnostic w / ultrasound (if necessary)o Unilateral Digital Diagnostic w / ultrasound (if necessary) R / L3D Tomosynthesis o Yes o No IMPLANTS? o Yes o NoDOES THE PATIENT HAVE PREVIOUS FILM? o Yes o No

(First) (MI) (Last)

ULTRASOUND

o Breast o R o L If palpable mass, please indicate location: ______________ o Transvaginal o Pelvic o Pelvic Sono o With transvaginal if necessary o OB Transabdominal o OB Transvaginal o OB Limited o OB Complete o Other __________________________________

o Other:

Appt. Date:___________________ Time:_________ A.M. P.M

For your convenience, you can also request an appointment online. To request anappointment, log onto www.TowerRadiologyCenters .com/appointmentrequest

EXAM PREPS AND MAP ON REVERSE SIDE

SERVICES MAY VARY BY LOCATION

q CC: Report To: ________________________

Rev. 9/16

Tampa’s First Outpatient Breast Imaging Center of Excellence

*ACR accreditations vary by modality

Designated by the American College of Radiology

� Wesley Chapel • 2324 Oak Myrtle Lane� North Dale Mabry • 17503 N. Dale Mabry Hwy� Carrollwood • 14499 N. Dale Mabry Hwy., Ste. 150� Bruce B. Downs • 3069 Grand Pavilion Dr.� Northside • 2716 University Square Dr.� Habana • 4719 N. Habana Ave.� South Tampa • 2106 S. Lois Ave.

� Brandon • 414 W. Robertson St.� Brandon • 500 Vonderburg Dr., W. Tower, Ste. 111� Brandon • 427 S. Parsons Ave., Ste. 100� Bloomingdale • 3350 Bell Shoals Rd� Riverview • 10689 Big Bend Rd., Ste. 102� Sun City • 3862 Sun City Center Blvd.

Scheduling: (813) 874.3177 • Fax: (813) 879.1809

MAMMOGRAPHY PATIENTS BEFORE YOU ARRIVE FOR YOUR EXAM:

• We strongly recommend that you bring any and all previous mammography and or ultrasound films with you at the time of your exam. These previous films will be used for comparison.• If you must have your films delivered, please arrange for them to arrive at the facility at least 2 days prior to your appointment.

JOHN

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RD.

PARS

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AVE

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PARS

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BIG BEND RD.

TOWER Radiology Center - Bloomingdale3350 Bell Shoals Road

813.654.4883

HENDERSON BLVD.

E. BRANDON BLVD.

S. K

ING

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E.

W. ROBERTSON ST.

SUN CITY CENTER BLVD.COLLEGE AVE.

5454 56

60

60

39

39

41

41

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92

ALT19

75

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4

75

75

275

275

275

580

640

TOLL589

TOLL589

301

301

301

92

574

NORTH

COLUMBIA DR.

BAYSHORE

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TOWER Radiology CenterWesley Chapel

2324 Oak Myrtle Lane813.751.0422

Within Cypress Creek Development

92

41

OLUMBIA DR.

LU

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TOWER Radiology Center - Vonderburg500 Vonderburg DriveWest Tower, Suite 111

813.654.5400

TOWER Radiology Center - Riverview10689 Big Bend Road, Suite 102

813.672.0608

TOWER Radiology Center - Robertson 414 W. Robertson St.

813.657.6767

TOWER Radiology Center - Parsons 427 S. Parsons Ave., Suite 100

813.315.2080

TOWER Radiology Center - Sun City 3862 Sun City Center Blvd.

813.642.9299

TOWER Radiology CenterBruce B. Downs

3069 Grand Pavilion Dr.813.977.9777

TOWER Radiology CenterNorth Dale Mabry

17503 N. Dale Mabry Hwy.813.968.4540

TOWER Radiology CenterCarrollwood

14499 N. Dale Mabry Hwy., Suite 150813.968.6998

TOWER Radiology Center - Habana

TOWER Breast Diagnostic Center - Habana4719 N. Habana Ave.

813.874.7000

TOWER Radiology Center - South Tampa2106 S. Lois Ave.

813.288.8839

TOWER Breast Diagnostic Center - Northside2716 University Square Drive

813.971.2050

INSTRUCTIONS & PREPARATION:

Please arrive 20 to 30 minutes prior to your scheduled appointment so that you will have time to fill out the necessary paperwork. MAMMOGRAPHY:

Do not use deodorant, perfume, powder or lotion before having your mammogram. BREAST BIOPSY: (Instructions for Stereotactic, Ultrasound and MRI) Arrive 1 hour prior to procedure. NPO* 2 hours before exam (3 hours for MRI Guided Biopsy). If you are on blood thinners (Coumadin, Plavix, etc.), contact our biopsy coordinator (813) 253-2721 ext. 1236. Wear a two piece, comfortable, loose fitting outfit with a sports bra or bra without underwire. A bra is required. BREAST MRI: Bilateral Diagnostic: NPO* 3 hours before exam. No estrogen or hormone replacement therapy (medication for Hot Flashes ONLY) for 4 weeks prior to exam. Continue all other hormones (example: For Chemotherapy, Thyroid Disease, Birth Control, etc...). Implants: (To rule out Rupture) NPO* 3 hours before exam. PELVIC MRI: Routine: NPO* 3 hours before exam. Dynamic: Water ONLY 3 hours prior to exam. Fetal: NPO* 3 hours before exam. ULTRASOUND: Pregnancy/Pelvic Sonogram: You must begin drinking about 1 hour prior to your exam time. Drink at least 32 ounces of liquid, stay away from caffeine drinks, over this time period. DO NOT go to the rest room; you must have a full bladder for your exam. DEXA SCAN: Please wear comfortable clothes, however refrain from wearing any metal accessories (i.e. zippers, buttons, etc.). No other preparation is necessary.

*NPO: Nothing By Mouth

IMPORTANT - PLEASE NOTEAny woman who is pregnant or thinks she might be pregnant should let the technologist or doctor know before beginning her exam. If you need

driving directions, log onto www.TowerRadiologyCenters.com and click on the facility locations. Find the facility and click on “driving directions”.

Fax: (813) 879-1809