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Demographics

WHEN YOU START THE DEMOGRAPHIC PLEASE INCLUDE THESE ITEMS:

1. DO NOT DISCLOSE PT INFORMATION, JUST CONFIRM IT
2. IS AN APARTMENT OR A HOUSE?
3. PLEASE GIVE ME A SECOND PHONE NUMBER?

Agree

              receipt

              Exam
            
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              Patient Name
            
              phone

              Telephone

              DOB

              payment

              Insurance

              local_hospital

              Refering Doctor

              Other Refering Doctor

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Note

APPOINTMENT NOTE DATA:

Questions

RX ON FILE

PT HAS RX PLEASE SEND THE RX BY SMS 833/204-5444 OR SCHEDULING@VITALIMG.COM

DR OFFICE HAS RX

FROM DOCTORS OFFICE WILL FAX PRESCRIPTION

N/A

PREPARATION

DON'T EAT SOLIDS, AND DON'T DRINK WATER, 6 TO 8 HOURS BEFORE THE EXAM.

PREPARATION

DRINK 32 ONZES OF WATER, 1 HOUR BEFORE THE EXAM.

PREPARATION

DON'T EAT AND DONT DRINK WATER FOR 6 TO 8 HOURS BEFORE THE EXAM.

PREPARATION

DON'T EAT FOR 5 TO 6 HORAS BEFORE THE EXAM; DRINK 32 ONZES OF WATER, ONE HOUR BERORE THE EXAM.

DIET SAMPLE:

THE DAY BEFORE THE EXAM: COMPLETE BREAKFAST AVOID DARK LIQUIDS AND FOR LUNCH AND DINNER: GRILLED CHICKEN BREAST OR GRILLED FISHED, RICE,
SALAD, SOUP, OR MASHPOTATOES.

PREPARATION

NO MORE SOLID EATING AFTER 6:00PM,
2 HOURS AFTER 6:00 PM APPLY THE FIRST ENEMA, CONTINUE WITH CLEAR LIQUIDS AND WATER,
5 HOURS BEFORE THE EXAM STOP CLEAR LIQUIDS, AND CONTINUE WITH ONLY WATER,
3 HOURS BEFORE EXAM APPLY THE SECOND ENEMA, CONTINUE WITH WATER
AND PRESTENT TO THE CENTER.

DIET SAMPLE:

BREAKFAST : COMPLETE BREAKFAST AVOID DARK LIQUIDS
LUNCH AND DINNER: GRILLED CHICKEN BREAST OR GRILLED FISHED, RICE,
SALAD, SOUP, MASHPOTATOES, AND CLEAR LIQUIDS.
PREPARATION

NO MORE SOLID EATING AFTER 8:00PM
2 HOURS AFTER 8:00 PM APPLY THE ENEMA. CONTINUE WITH CLEAR LIQUIDS AND WATER
5 HOURS BEFORE THE EXAM STOP CLEAR LIQUIDS, AND CONTINUE WITH ONLY WATER
AND PRESTENT TO THE CENTER.

DIET SAMPLE:

BREAKFAST : COMPLETE BREAKFAST, AVOID DARK LIQUIDS.
LUNCH AND DINNER: GRILLED CHICKEN BREAST OR GRILLED FISHED, RICE,
SALAD, SOUP, MASHPOTATOES AND CLEAR LIQUIDS.
PREPARATION

NO MORE SOLID EATING AFTER 8:00PM,
2 HOURS AFTER 8:00 PM APPLY THE ENEMA, CONTINUE WITH CLEAR LIQUIDS AND WATER,
5 HOURS BEFORE THE EXAM STOP CLEAR LIQUIDS, CONTINUE WITH ONLY WATER,
AND PRESTENT TO THE CENTER.

PREPARATION

DON'T EAT FOR 5 TO 6 HORAS BEFORE THE EXAM; TAKE MEDICINE WITH MINIMUM OF WATER.

HOW SCHEDULE THIS APPOINTMENT AND EXAM INFORMATION

TRANSPORTATION

YES

APPROVED BY:

N/A

NO

SPECIAL NEEDS
IF THE PATIENT HAS SPECIAL NEEDS THEY MUST HAVE REDUCED MOBILITY AND BE ABLE TO ACCESS THE MACHINE BY THEMSELVES OR WITH THE MINIMAL HELP OF A COMPANION
WHICH SPECIAL NEED?

NO

N/A

AWARE OF COMPANION SPECIAL NEEDADULT PERSON WHO CAN DRIVE

YES

NO

PT AWARE OF PREPS

YES

NO

1 ENEMA

2 ENEMA

FASTING 4 HOURS

FASTING 6 HOURS

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Priors

Do Not Bring Jewelry, Any Metal Objects Or Any Valuable Items Because The Centers Will Not Be Responsible For Them

The day before the apppointment we will call you
to confirm all this information and copay, if it is necessary.
For transportation: On the day of the appointment we
will call you 60 minutes before to confirm the exact pick up time
Farewells: Is there something else, Can I help you with?.
Thank you for choosing Vital Imaging

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Demographicsinfo_outline

WHEN YOU START THE DEMOGRAPHIC PLEASE INCLUDE THESE ITEMS:

Note

Questions

Demographics