Agency Fax:
*
Comments:
Agency Name:
*
Doctor's NPI:
Ordering Physician:
*
Phone:
*
First Name:
*
Rx
We were unable to upload your file. Please ensure your file is 10MB or smaller in size.
Primary Dx:
*
X-Ray HEAD/FACIAL:
Skull Series
Facial Bones
Orbits
Mandible
Sinuses/Nasal
2nd Phone:
Last Name:
*
American X-ray Services, LLC Portable X-Rays
Online
Order Form f
or Portable Diagnostic Procedures
Agency Phone:
*
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 SPINE:
Cervical Spine
Thoracic Spine
Lumbosacral Spine
Sacrum & Coccyx
Abdomen (KUB)
Pelvis
Date of Birth:
*
Electronic Signature
*
I acknowledge that a signed doctor's order is on file and will be made available to American X-Ray Services.
Nurses Name:
X-Ray CHEST:
Chest (PA & Lat)
Chest (AP only)
Ribs (Bilateral)
Ribs (LT)
Ribs (RT)
Full Address:
*
Downloadable PDF Form
Medicare Part B#
*
Upload Order/File
We were unable to upload your file. Please ensure your file is 10MB or smaller in size.
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)
Thank you for your order! Please call if needed for any additional information.
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