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Cushing Memorial Hospital
Leavenworth, KS 66048
Radiology Scheduling
To schedule call (913) 684-1156/1155
To schedule via fax: (913) 684-1236
Home Phone: _____________ Alternate: ______________ Special Instructions: Primary Care Physician:
Insurance Type
Ordering Physician (print):
Ordering Physician (signature):
ULTRASOUND
HEAD X-Ray
o Joint – Specify RT, LT, or Bilateral CHEST X-Ray
EXTREMITY
ABDOMEN X-Ray
NUCLEAR MEDICINE
CT SCAN: IV CONTRAST YES
NO
GASTROINTESTINAL/GU
ARTHROGRAM With MRI
BONE DENSITY STUDY
MAMMOGRAPHY
Unlisted Exam
________________________________
FOR SCHEDULERS ONLY:
Appointment Date: _____________ Time: __________ Attempts made to contact patient: _________
Patient Label:
Page 1 of 2 CMH-XR-1402 (Rev. 11/12/09) Cushing Memorial Hospital
Leavenworth, KS 66048
Radiology Scheduling
Important Information Regarding Your Examination: • If you are on any medications that are necessary to take on a
daily basis, please do not withhold these medications without checking with our technologists. If you take glucophage,
metformin, glucovance, metaglip, or advandamet please alert our office at the time of scheduling. • If you have any allergies
to iodine, other medications, or have asthma, please contact us prior to your examination. • If there is any possibility you
might be pregnant, please let us know when scheduling. • If you have any questions regarding your examination, please
contact our office. If for any reason you cannot make your scheduled appointment, please call to reschedule
at 913-684-1156.

Examination Preparation Instructions:

UPPER GI SERIES:
Do not eat or drink anything (not even water) after midnight the day of your examination.
BARIUM ENEMA: You must pick up a LO-SO prep kit in the radiology department two days prior to your study.
Follow the 24-hour prep instructions in the kit.
IVP: You must pick up a LO-SO prep kit in the radiology department two days prior to your study. Follow the 24-
hour prep instructions. Drink lots of liquids. Do not eat or drink anything four hours prior to your test.
Absolutely no dairy products.

SMALL BOWEL: Nothing to eat or drink after midnight.
MAMMOGRAM: No body powder, lotions, or deodorant prior to exam. Please bring prior mammograms with you
to your scheduled appointment. If this is not possible, you will need to provide the information needed to obtain
these studies for comparison.
ULTRASOUNDS
US ABDOMEN/GALLBLADDER: Do not eat or drink anything after midnight until after your examination is
completed.
PELVIS/Obstetrical US: One hour prior to examination time, you need to drink 32 oz. of fluid (water or tea) to fill
your bladder. Do not urinate before your examination is completed. Please avoid carbonated beverages.
ALL MRIs: Please alert scheduler at time of scheduling if you have a pacemaker, any implants, implantable
pumps, vena cava filters, or metal in the eyes. Please leave all jewelry and valuables at home.
MRCP: Nothing to eat or drink 12 hours prior to your appointment.
MRI CHILDREN: Children may have nothing to eat or drink four hours prior to the appointment time.
CT HEAD, NECK IAC: Nothing to eat or drink four hours prior to your appointment.
CT ABDOMEN AND PELVIS: In most cases once you arrive, you will be expected to drink oral contrast over a
one or two hour period before the scanning begins, depending upon the area to be examined. Oral contrast can
also be picked up prior to your appointment date and drank at home.
a.m. appointments: Nothing to eat or drink after midnight the evening before your examination.
p.m. appointments: Nothing to eat or drink four to six hours prior to your appointment time.
CT ORBITS: Nothing to eat or drink four to six hours prior to your appointment time.
CT CHEST: Nothing to eat or drink four hours prior to appointment time. Be sure to bring any previous chest
X-rays with you to your appointment.
CT ANGIOGRAPHY: Do not eat or drink four hours prior.
Patient Label:
Page 2 of 2 CMH-XR-1402 (Rev. 11/12/09)

Source: http://www.cc-pc.com/sites/default/files/files/PDFs/Servicelines/Imaging%20(Radiology)/RadiologyOrder_CMH.pdf

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