SMB Sonography
Patient Name
Phone
Pregnant
YES NO
EDD/LMP
Email
Reason for the Exam
Provider Name
Provider Phone #
NPI #
Where should this report be sent to SelectEmailFax Number
Provider Email
Fax Number #
ABDOMEN COMPLETE (76700) ABDOMEN LMTD (76705) RUQLUQ RENAL COMPLETE (76770) BLADDER (PVR ONLY) (76857) HERNIA (SITE) APPENDIX (76705)
PELVIC COMPLETE TA/TV (76856/76830) PELVIC (T/A) (76856) PELVIC (TV) (76830) FOLLICULAR TRACKING (76830)
THYROID (76536) SCROTUM w/DUPLEX (76870) SOFT TISSUE NECK (76536) SOFT TISSUE BACK CHEST (76604) EXTREMITY (NON VASC LMTD) (76857) RTLT
VENOUS LEGS/BILATERAL (93970) VENOUS LEG (93971) RTLT VENOUS ARMS/BILATERAL (93970) VENOUS ARM (93971) RTLT AAA (76706) CARTOID (93880)
OB (<14 weeks) Dating (76801) OB (>14 weeks) Anatomy (76805) OB Transvaginal (76817) OB BPP w/o NST (76819) OB FollowUp Growth (76816) OB Lmtd (AFI, FHR, Position, Placenta) (76815) OB >14weeks Add Fetus (76810)
UNILATERAL BREAST (76642) (Acute symptoms) OTHER EXAM REQUESTED