Get X Ray Request Form

Life Chiropractic College West Health Center X-Ray Request Form Patient Name Field Dr. M/F DOB Field DR. Acct Mailing address Dr. Signature Dr Telephone -Fill out all fields list best days and time ranges for patient. 780-4559 -We will schedule with your office directly. Our phone is 510 -FAX this form to us at 510 780-4511. -A 25. 00 fee may be charged if your patient fails to show up for their appointment. Bill Doctor s credit card on file Patient to pay on day of service Plain Film X-ray Digital X-ray CD for computer Request for DACBR report Note Billed separately by mail Cervical X rays LAT APOM APLC 3 views Cervical obliques 2 views Cervical Lateral bending 2 views Thoracic X rays AP LAT 2 views Chest PA 1 view Lumbo-pelvic X rays Lumbar Flex/Ext 2 views Lumbar obliques 2 views Lumbar Lateral bending 2 views Lumbosacral lateral spot 1 view PA sacral tilt 1 view Modified Ferguson 1 view Ankle 3 views LeftRight Foot 3 views LeftRight Knee 2 views LeftRight Hand 3 views LeftRight Wrist 4 views LeftRight Elbow 3 views LeftRight Shoulder 2 views LeftRight Hip 2 views LeftRight Other Best days/times for patient TOTAL number of views Please do not write below this line Appointment scheduled for Date Time For use on day of x ray only by LCCW faculty Female Patients There is no possibility that I am pregnant today. Signature Dr Telephone -Fill out all fields list best days and time ranges for patient. 780-4559 -We will schedule with your office directly. Our phone is 510 -FAX this form to us at 510 780-4511. -A 25. 00 fee may be charged if your patient fails to show up for their appointment. Our phone is 510 -FAX this form to us at 510 780-4511. -A 25. 00 fee may be charged if your patient fails to show up for their appointment. Bill Doctor s credit card on file Patient to pay on day of service Plain Film X-ray Digital X-ray CD for computer Request for DACBR report Note Billed separately by mail Cervical X rays LAT APOM APLC 3 views Cervical obliques 2 views Cervical Lateral bending 2 views Thoracic X rays AP LAT 2 views Chest PA 1 view Lumbo-pelvic X rays Lumbar Flex/Ext 2 views Lumbar obliques 2 views Lumbar Lateral bending 2 views Lumbosacral lateral spot 1 view PA sacral tilt 1 view Modified Ferguson 1 view Ankle 3 views LeftRight Foot 3 views LeftRight Knee 2 views LeftRight Hand 3 views LeftRight Wrist 4 views LeftRight Elbow 3 views LeftRight Shoulder 2 views LeftRight Hip 2 views LeftRight Other Best days/times for patient TOTAL number of views Please do not write below this line Appointment scheduled for Date Time For use on day of x ray only by LCCW faculty Female Patients There is no possibility that I am pregnant today. Signature Dr Telephone -Fill out all fields list best days and time ranges for patient. 780-4559 -We will schedule with your office directly. Our phone is 510 -FAX this form to us at 510 780-4511. -A 25. 00 fee may be charged if your patient fails to show up for their appointment. Bill Doctor s credit card on file Patient to pay on day of service Plain Film X-ray Digital X-ray CD for computer Request for DACBR report Note Billed separately by mail Cervical X rays LAT APOM APLC 3 views Cervical obliques 2 views Cervical Lateral bending 2 views Thoracic X rays AP LAT 2 views Chest PA 1 view Lumbo-pelvic X rays Lumbar Flex/Ext 2 views Lumbar obliques 2 views Lumbar Lateral bending 2 views Lumbosacral lateral spot 1 view PA sacral tilt 1 view Modified Ferguson 1 view Ankle 3 views LeftRight Foot 3 views LeftRight Knee 2 views LeftRight Hand 3 views LeftRight Wrist 4 views LeftRight Elbow 3 views LeftRight Shoulder 2 views LeftRight Hip 2 views LeftRight Other Best days/times for patient TOTAL number of views Please do not write below this line Appointment scheduled for Date Time For use on day of x ray only by LCCW faculty Female Patients There is no possibility that I am pregnant today. .