RADIOLOGY CONTACT INFORMATIONCentral SchedulingDiagnostic Studies 310 301Interventional Radiology Clinics 310 4817545Interventional Radiology Procedures 310 8255565Scheduling Fax 10 7949035Image Libra ID: 887717
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1 uclahealth.org/radiologyRev./19 RADIOL
uclahealth.org/radiologyRev./19 RADIOLOGY CONTACT INFORMATION Central Scheduling(Diagnostic Studies): (310) 301Interventional Radiology Clinics: (310) 4817545Interventional Radiology Procedures: (310) 8255565Scheduling Fax: (10) 7949035Image Library: (310) 8256425 Authorizations(310) 3018899Cash pricing for select studiesuclahealth.org/cashpricingAppt Reminders, Preps & Full Reports: my.uclahealth.org RADIOLOGY ORDER(Outpatient) Patient Name Date Reason for s tudy (Diagnosis), Clinical history and uestions for the radiologist: Waive Creatinine Requirement (for Contrast Studies) DOB MRN Print Label if Available Ordering Provider: ______________________________ Request (check one): Stat Routine P rint ______________________________ Appt . Date: ___________ Appt . Time : ___________ Phone (if STAT) S ignature General X - ray Ultrasound 堀刀⁃栀攀猀琀 倀䄠☠䰀䅔 唀匀⁁戀摯洀敮⁃潭灬整攀 堀刀⁋唀䈀 唀匠䭩搀渀攀礀 堀删䌀 匀瀀椀渀攠匀敲椀敳 堀删䰀 匀灩渀攠匀敲椀敳 吀爀慮猀瘀慧椀湡氀 堀刀 䅐⁌䅔 䠀椀瀀⁓攀爀椀攀猀⁷⼀⁁倠倀攀氀瘀椀猀 Bilat �… R �… L �… US Thyroid/Parathyroid XR Knee Series �… Bilateral �… Right �… Left US Doppler Leg(s) Veins �… Bilat �… Right �… Left Other: _______________________________________ Other: _______________________________________ CT MRI CT Brain �… w/o contrast MRI Brain �… w/ & w/o contrast �… w/o contrast CT Sinus �… w/o contrast MRI C - Spine �… �… w/o contrast CT Chest �… w/ contrast �… w/o contrast M RI L - Spine �… w/ & w/o contrast �… w/o contrast CT Abdomen & Pelvis �… w/ contrast �… w/o contrast MRI Abdomen �… w/ & w/o contrast �… w/o contrast CTA Chest �… w/wo contrast �… w contrast MRI Pelvis �… w/ & w/o contrast �… w/o contrast CT C oronary Calcification Screening �… w/o contrast MRI Knee w/o contrast �… Bilateral �… Right �… Left Other: _______________________________________ Other: _______________________________________ Breast Imaging PET/CT Screening 3D Mammo �… Bilateral �… Right �… Left PET/CT Whole Body + Diag CT �… w/ con �… w/o con Screening 2D Mammo �… Bilateral �… Right �… Left PET/CT Skull base to Mid - Thigh + Diag CT �… w/ con Diagnostic Mammogram �… Bilateral �… Right �… Left PET/CT Skull base to Mid - Thigh + Diag CT �… w/o con Screening Breast US �… Bilateral �… Right �… Left �… PET/CT Skull base to Mid - Thigh (CT for atten/correct) �… Bilateral �… Right �… Left �… PET/CT Whole Body (CT for att enuation/correction) �… MRI Breast – Bilateral w/ and w/o contrast �… PET Brain Other: _______________________________________ Other: _______________________________________ Interventional Radiology Neuro/ Spine/ Pain Management Interventions & Procedures �… Lumbar �… Thoracic �… Cervical Dx: __________________________________________ �… Interlaminar Epidural �… Transforaminal Epidural �… Interventional Radiology Consult �… Facet Block �… Nerve Block Preferred Clinician:___________________________ �… Sacroiliac Joint �… Spine Biopsy
2 �… Porta - Cath �
�… Porta - Cath �… Permacath �… Hickman �… PICC �… Bone RFA �… Vertebroplasty �… Kyphoplasty �… Biopsy: ____________________________________ �… Other: _____________________________________ �… Drainage:__________________________________ �… Ablation:___________________________________ Sports Injury Procedures �… Embolization:_______________________________ �… Bilateral �… Right �… Left �… Angioplasty / stent placement:__________________ MR Arthrogram: �… Shoulder �… Hip �… Wrist �… Elbow �… Venous thrombolysis / recanalization �… TIPS Joint Injection: �… Hip �… Shoulder �… Other _________ �… IVC filter placement �… IVC filter removal �… US guided joint injection/aspiration �… Varicose vein treatment �… Fluoroscopy guided joint injection/aspiration �… Other: _____________________________________ �… Other: _____________________________________ uclahealth.org/radiologyocations and Services The Department of Radiology includes many convenient locations and unique subspecialtyservices to improve the lives of patients every day. Our goal is to provide patient centered care, superior diagnostic access andoptimal treatment expertise. Radiology Central Scheduling: (310) 301 - 6800 Request Self - Pay/Cash Rates: (310) 301 - 8806 Radiology Scheduling Fax: (310) 794 - 9035 o Cash Rates a vailable online: uclahealth.org/cash - pricing Interventional Radiology Clinics: (310) 481 - 7545 Request Copies of Imaging Studies (Images) : (310) 825 - 6425 Authorization Customer Service: (310) 301 - 8899 Full Written Radiology Reports: my.uclahealth.org ImagingLocation Address Free Parking MR CT MAMMO US X-RAY DEXA IR PET/CT WESTWOOD UCLA Medical Plaza Imaging and Interventional Center 100, 200, 300 UCLA Medical Plz . Los Angeles, CA 90095 Ronald Rea gan UCLA Medical Center 757 Westwood Plaza Los Angeles, CA 90095 SANTA MONICA Santa Monica Outpatient Imaging and Interventional Center 1245 16th St., #100, #105, #110 Santa Monica, CA 90404 Barbara Kort Women’s Imaging Center 1260 15th Street, # 111 Santa Monica, CA 90404 ⠀嘀愀氀椀摡琀敤 倀愀爀欀椀湧 Beach Imaging andInterventional Center 1919 Santa Monica Blvd., # 300 Santa Monica, CA 90404 ⠀嘀愀氀椀摡琀敤 倀愀爀欀椀湧 UCLA Medical Center, Santa Monica 1250 16th Street Santa Monica, CA 90404 SOUTH BAY Manhattan Beach Imaging and Interventional Center 2200 N. Sepulveda Boulevard Manhattan Beach CA 90266 Palos Verdes Imaging and Interventional Center 501 Deep Valley Dr ive , 4 th Floor Rolling Hills Estates, CA 90274 Palos Verdes Women’s Imaging Center 501 Deep Valley Dr ive, 3 rd Floor Rolling Hills Estates, CA 90274 VALLEY Santa Clarita Imaging and Interventional Center 27235 Tourney Road , #1500 Valencia, CA 91355 Westlake Village Women’s Imaging Center 30700 Russell Ranch Roa d , #110 Westlake Village, CA 91362 UCLA Radiology supports Ultrasound, walkin XRayand Mammography services in various UCLA Health Clinics. Beverly Hills – Primary & Specialty Care 2020 Santa Monica Blvd. BuildingUCLA Spine Center, Santa MonicaRedondo BeachUCLA Primary & Specialty CareTorranceUCLA Primary & Specialty Care (Lomita Blvd.)TorranceUCLA Primary & Specialty Care (Skypark Dr. Marina Del Rey Urgent Care & Primary Care Porter Ranch – UCLA Primary & Specialty Care Thousand OaksUCLA Primary & Specialty CareWoodland HillsFamily Medicine, Internal Medicine & Pediatrics Urgent CareThe Village at Westfield TopangaEncinoPrimary & Specialty CareServices may be limited and not offered at every location. See the full list at uclahealth.org/radiology/ourlocations