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Primary Dx:
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American X-ray Services, LLC Portable X-Rays
Online
Order Form f
or Portable Diagnostic Procedures
Agency Phone:
*
Agency Fax:
*
Comments:
Nurses Name:
X-Ray HEAD/FACIAL:
Skull Series
Facial Bones
Orbits
Mandible
Sinuses/Nasal
X-Ray UPPER EXTREMITIES:
Shoulder/Clavicle (Bilateral)
Clavicle (LT)
Clavicle (RT)
Scapula (Bilateral)
Scapula (LT)
Scapula (RT)
Shoulder (Bilateral)
Shoulder (LT)
Shoulder (RT)
Humerus (Bilateral)
Humerus (LT)
Humerus (RT)
Elbow (Bilateral)
Elbow (LT)
Elbow (RT)
Forearm (Bilateral)
Forearm (LT)
Forearm (RT)
Wrist (Bilateral)
Wrist (LT)
Wrist (RT)
Hand/Fingers (Bilateral)
Hand/Fingers (LT)
Hand/Fingers (RT)
X-Ray LOWER EXTREMITIES:
Hip (Bilateral)
Hip (LT)
Hip (RT)
Femur (Bilateral)
Femur (LT)
Femur (RT)
Knee (Bilateral)
Knee (LT)
Knee (RT)
Tibia/Fibula (Bilateral)
Tibia/Fibula (LT)
Tibia/Fibula (RT)
Ankle (Bilateral)
Ankle (LT)
Ankle (RT)
Calcaneus (Bilateral)
Calcaneus (LT)
Calcaneus (RT)
Foot/Toes (Bilateral)
Foot (LT)
Foot (RT)
Downloadable PDF Form
X-Ray CHEST:
Chest (PA & Lat)
Chest (AP only)
Ribs (Bilateral)
Ribs (LT)
Ribs (RT)
X-Ray SPINE:
Cervical Spine
Thoracic Spine
Lumbosacral Spine
Sacrum & Coccyx
Abdomen (KUB)
Pelvis
Gender:
Unknown
Male
Female
Agency Name:
*
Doctor's NPI:
2nd Phone:
Ordering Physician:
*
Full Address:
*
Medicare Part B#
*
Date of Birth:
*
Last Name:
*
Phone:
*
First Name:
*
Thank you for your order! Please call if needed for any additional information.
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