SECURED ONLINE ORDER FORM – Lifecare Imaging

1631 Rand Rd,Suite C,Des plaines-60016 | Phone: 1-800-919-1761 | Fax: 1-800-919-1761

Nature of Order

ROUTINE ORDER (24 Hours turnaround time)
LIFE THREATNING STAT (Only for LIFE THREATNING SYMPTOMS OR CIRCUMSTANCES. 4 Hours turnaround time. Signed copy of the order indicating "STAT" is mandatory). Please note: NO STAT EKG service.

Organization Name

Please enter facility name/organization

Phone Number

Please enter facility phone number

Fax Number

Please enter facility fax number

Please provide if requesting results to specified email

Patient Name

First

Middle

Last

Date Of Birth

Gender

SSN Number

Room Number and Bed Number:

Please specify building, unit, room and bed numbers

Address/Contact Information/Telephone Number:

Please fill out if home patient.

Special Instructions

Please specify if any special instructions

Primary Insurance Provider:

Insurance ID/Authorization Number:

Ordering Physician/NP:

First

Last

ABOVE Order Procedure(s):

Date Of Service

PLEASE SELECT PROCEDURE(S):

Other Procedure(s): **PLEASE SELECT "OTHER PROCEDURE" FROM THE ABOVE DROP DOWN MENU**

Please specify in detail

REASON FOR SERVICE: PLEASE LIST THE PATIENT’S SPECIFIC SIGNS & SYMPTOMS – “R/O IS NOT ACCEPTABLE

Nurse Name

First

Last

Nurse Initials

Patient Document Upload

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