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AMIC Radiology STAT Call Form
Published: 12/14/2023
All Items Must be Completed
Site
Select Site
AFM VillageMD
Bridgeport
Casper Orthopedics
FMC
Grand Avenue Urgent Care
Greeley Emergency and Surgery Center
HIC
Ivinson
Kimball
Longmont Clinic
Longs Peak Hospital
MCR
Monfort Family Clinic
Pediatric Urgent Care of Northern Colorado
PET Imaging of Northern CO
Premier Bone and Joint
PVH
Sidney Regional
Summit Medical Center
UCH Aspire
UCH Broomfield Hospital
UCH Carbon Valley Medical Center
UCH Cherry Creek Medical Center
UCH Eagle Urgent Care
UCH Elk Lakes Medical Center
UCH Firestone Urgent Care
UCH Greeley Hospital
UCH Harmony ED
UCH Johnstown Urgent Care
UCH Longmont Urgent Care
UCH LPMC
UCH Mason
UCH Orchard Internal Medicine
UCH Peakview Urgent Care
UCH Stonegate
Windsor Imaging
WMA
Yuma
Please Select the Site
Patient Name (Last, First)
,
last name required
first name required
Source
Select Source
ER
INPATIENT
OUTPATIENT
URGENT CARE
TO
CARDOVERREAD
Please Select the Source
Modality
Select Modality
CR
CT
Fluoro
MG
MR
NUC MED
PET
US
OTHER
DX
Please Select the Modality
Exam Description
description required
History
history required
Call Report To Name:
report to required
Call Report to Phone#:
phone required
Call Required
Stroke Alert
Stroke
or
LVO
These fields will only be enabled if the requesting site has patient waiting enabled.
Is the patient waiting
yes
no
Please check yes or no
Patient Location
patient location required
Please do not enter the patient's personal phone number in this field.
Patient Location Phone
patient location phone required
For use only during a EPIC downtime.
Down Time Exam
****** Please indicate if this a STAT exam ******
STAT Exam
Contrast Amount in ML:
Contrast Type:
Please be patient after hitting Submit
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