Requisition Form - American River Diagnostics Imaging

Skip to content

Home
About Us
Services
Contact Us

Home
About Us
Services
Contact Us

Requisition Form

Home
Requisition Form

Step 1 of 3

33%

ULTRASOUND EXAMS REQUISITION FORM

Patient Name(Required)

First Last

Date of Birth(Required)

MM slash DD slash YYYY

Sex(Required)

Male

Female

Other

Phone(Required)

Patient ID / MRN(Required)

Facility Name

Facility Phone Number

Email(Required)

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

ABDOMEN/RUQ(Required)

Complete Abdomen

Limited Abdomen

Liver

Gallbladder

Pancreas

Spleen

Abdominal Aorta

Appendix

Ascites/RUQ

Renal / Kidneys
Prep: If possible drink if possible 1-3 cups water/ fluid for:

Kidneys with Bladder

Bladder Only

Post-Void Residual

Pelvic Male/female

Pelvic Complete

Prostate

VASCULAR :(Required)

Carotid Artery Duplex

Upper Arm Venous: Right

Upper Arm Venous: Left

Upper Arm Venous: Bilateral

Upper Arm Arterial: Right

Upper Arm Arterial: Left

Upper Arm Arterial: Bilateral

Lower Leg Venous DVT Right

Lower Leg Venous DVT Left

Lower Leg Venous DVT Bilateral

Leg Arterial Right

Leg Arterial Left

Leg Arterial Bilateral

SMALL PARTS:(Required)

Thyroid

Breast : Right

Breast : Left

Breast : Bilateral

Chest Right

Chest Left

Chest Bilateral

Scrotum

Mass: body area/side:

Hernia body area/side:

Lymph Node: body area/side:

Others, body area/side:

Mass: body area/side:(Required)

Hernia body area/side:(Required)

Lymph Node: body area/side:(Required)

Others, body area/side:(Required)

Tech Notes

Ordering Physician

Signature

Phone

Main Provider(Required)

Clinical Indication/ Symptoms/ History

NOTES(Required)

Prepared by:

Signature

Date

PLEASE ATTACH FACE SHEET AND DOCTOR’S ORDER IF HANDWRITTEN OR DONE IN A SEPARATE SYSTEM/ONLINE.

We aim to service nursing homes, clinics, and any other private or public community setting.

At ARUD, we go beyond delivering scans; we partner with you throughout the entire care process, friendly communication.

our services

General / Abdominal
Vascular
Cardiac ECHO
Small Parts /Extremity / Superficial/ MSK

General / Abdominal
Vascular
Cardiac ECHO
Small Parts /Extremity / Superficial/ MSK

contact us

(916) 846-3254‬
ultrasoundrad@gmail.com

We aim to service nursing homes, clinics, and any other private or public community setting.

At ARUD, we go beyond delivering scans; we partner with you throughout the entire care process, friendly communication.

Telegram-plane Vk Odnoklassniki

Useful Links

Home
About Us
Services
Contact Us

our services

General / Abdominal
Vascular
Cardiac ECHO
Small Parts /Extremity / Superficial/ MSK

contact us

+1 (279) 275-3125
1 (800) 914-4670
ultrasoundrad@gmail.com
3589 Rainsong Cir

© 2025 American River Diagnostics Imaging