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Medicalcityhospital.com

Scheduling: 972-612-6525 Fax: 469-484-2326
Diagnosis (All test/procedures ordered must have a diagnosis and reason for testing) Physician's Signature (required for order)
To request radiology images or reports contact us at 972-566-7226
3-D Reformation
BILATERAL
Fluoroscopy
Nuclear Medicine
Radiology
Rapidscreen
Chest CAD will be
completed on all
chest x-rays. We
will follow
protocols for age
and timeliness.
BILATERAL
Pregnancy Test Electrocardiogram (Blood Serum) (EKG) 7777 Forest Lane Dallas, Texas 75230 (972) 566-7000 IMAGING ORDER FORM
(All test/procedures ordered must have a diagnosis code and reason for testing) Physician's Signature (required for order)
Vascular/Interventional - For these exams contact 972-566-7866 (phone) or 972-566-6290 (fax)
Kyphoplasty - For these exams contact 972-566-7866 (phone) or 972-566-6920 (fax)
Thoracic Spine (Level ) Lumbar Spine (Level )
Please check all signs and symptoms related to this patient (Kyphoplasty only)
Closed thoracic fx w/o spinal cord injury (additional information needed regarding cause) Closed lumbar fx w/o spinal cord injury (additional information needed regarding cause) Compression fx (additional information needed regarding cause) Pathologic fx (additional information needed regarding cause) For More Information about Your Procedure visit us at: Medical City Imaging at
Medical City Dallas Hospital
7777 Forest Lane
Building D, Suite 200
Dallas, Texas 75230
PARKING: Parking access to Building D is located at the corner of Park Central
and Merit Drive. Building D valet parking available from 8:00 a.m. to 5:00 p.m.
Visitor Parking is open 24 hours a day at the corner of Forest Lane and Park
Central Drive for Buildings A,B, and C. Parking fees are as follows:

Up to 1 hour: $1.00 61 minutes - 2 hours: $2.00 Over 4 hours: $4.00
Valet Parking for visitors is available Monday through Friday for $4.00 per
day at Building A and C from 8:00 a.m.-6:00 p.m., and at Building D from
8:00 a.m.-5:00 p.m.

Parking Meters are also available on Park Central Drive.
7777 Forest Lane Dallas, Texas 75230 (972) 566-7000 IMAGING ORDER FORM

Source: http://medicalcityhospital.com/services/imaging/outpatient-imaging-order-form.pdf

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