American X-Ray Services Portable X-Rays Health Care Providers May Fill Out the Online Order Form for Portable Diagnostic Procedures Below "*" indicates required fields Patient First Name:* First Patient Last Name:* First Gender:UnknownMaleFemaleDate of Birth:* MM slash DD slash YYYY Medicare Part B#*Phone*2nd Phone:Full Address:* Address Line 2 City IL ZIP / Postal Code Ordering Physician:*Doctor's NPI*Agency Name:*X-Ray HEAD/FACIAL: Skull Series Facial Bones Orbits Mandible Sinuses/Nasal X-Ray CHEST: Chest (PA & Lat) Chest (AP only) Ribs (Bilateral) Ribs (LT) Ribs (RT) X-Ray SPINE: Cervical Spine Thoracic Spine Lumbosacral Spine Sacrum & Coccyx Abdomen (KUB) Pelvis 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 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) Primary Dx:*Nurses Name:Agency Phone:*Agency Fax:*Comments:Electronic Signature* I acknowledge that a signed doctor's order is on file and will be made available to American X-Ray Services.Upload Order/FileMax. file size: 1 GB.RxMax. file size: 1 GB.NameThis field is for validation purposes and should be left unchanged. Downloadable PDF Form A Signed Doctor’s Order will be made available to American X-Ray Services
