Austin Imaging and Lab | Provider Form

Patient Name

Phone Number*

Email*

Pregnant?

Yes

No

EDD/LMP

Reason for the Exam

Provider Information: Provider Name

Provider Phone Number*

NPI Number

Where should this report be sent to?

Email

Fax Number

Based On Above, Please Enter Email or Fax

Gynecology

PELVIC COMPLETE TA/TV (76856/76830)

PELVIC (T/A) (76856)

PELVIC (TV) (76830)

FOLLICULAR TRACKING (76830)

Obstetrics

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)

MISC

UNILATERAL BREAST (76642)

(Acute symptoms)

OTHER EXAM REQUESTED

Provider Form

Use the form below to send us your provider information so we can process your requests quickly and accurately.

San Marcos, TX

Round Rock, TX

Austin, TX