Every diagnostic image at MIC starts with a requisition form filled out by a practitioner. All MIC requisitions are available as auto-fill forms in your EMR. We will also supply your office with hard copies or you can print them using the downloadable pdf forms below.
By completing the requisitions below, you are confirming you are an authorized licensed practitioner.
Requisition Forms
General Requisition:
The general requisition lists common exams at MIC, including x-ray, ultrasound, nuclear medicine, bone densitometry, body composition, etc.
Cardiac Requisition:
The cardiac requisition lists cardiac exams offered at MIC, including myocardial perfusion imaging (MPI), echocardiograms, exercise stress tests, and more.
MRI & CT Requisition:
The MRI & CT requisition lists exams at MIC that utilize magnetic resonance imaging or computed tomography to examine the brain, spine, abdomen, pelvis, etc.
Pain Management Requisition:
The pain management requisition lists specialized procedures at MIC which help alleviate pain caused by inflammatory joints, soft tissue, or other chronic conditions.
PET CT Requisition:
The PET CT requisition lists specialized exams offered at MIC that utilize positron emission tomography and radiopharmaceuticals to examine the brain, heart, etc.
Women's Imaging Requisition:
The women’s imaging requisition lists common exams at MIC for women, including breast imaging, obstetric ultrasound, and more.
VIRNA Requisition - Vascular & Interventional Radiologists of North America:
The VIRNA requisition includes procedures such as gynecologic/genitourinary intervention, venous intervention and more.
Exam Preparation Forms
General:
Lists general exam preparation instructions for Ultrasound, Mammography and Nuclear Medicine examinations.
Cardiac:
Lists preparation instruction information for Cardiac examinations.
MRI & CT:
Lists preparation instruction information for MRI & CT examinations.
Pain Management:
Lists preparation instruction information for Pain Management examinations and procedures.
PET CT:
Lists preparation instruction information for PET CT examinations.
Women's Health Imaging:
Lists preparation instruction information for Women’s Health Imaging examinations.
Virtual Colonoscopy:
Virtual Colonoscopy preparation instructions.