{"id":333,"date":"2023-01-17T19:04:05","date_gmt":"2023-01-17T19:04:05","guid":{"rendered":"https:\/\/uabmedicine.org\/blogs\/greyform\/?page_id=333"},"modified":"2023-01-17T19:05:45","modified_gmt":"2023-01-17T19:05:45","slug":"ordering-diagnostic-imaging","status":"publish","type":"page","link":"https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/index.php\/ordering-diagnostic-imaging\/","title":{"rendered":"Ordering Diagnostic Imaging"},"content":{"rendered":"<script type=\"text\/javascript\">if(!gform){document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0});var gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),null==t&&(t=10),gform.hooks[o][n].push({tag:i,callable:r,priority:t})},doHook:function(o,n,r){if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[o][n]){var t,i=gform.hooks[o][n];i.sort(function(o,n){return o.priority-n.priority});for(var e=0;e<i.length;e++)\"function\"!=typeof(t=i[e].callable)&#038;&#038;(t=window[t]),\"action\"==o?t.apply(null,r):r[0]=t.apply(null,r)}if(\"filter\"==o)return r[0]},removeHook:function(o,n,r,t){if(null!=gform.hooks[o][n])for(var i=gform.hooks[o][n],e=i.length-1;0<=e;e--)null!=t&#038;&#038;t!=i[e].tag||null!=r&#038;&#038;r!=i[e].priority||i.splice(e,1)}}}<\/script>\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper' id='gform_wrapper_32' style='display:none'><div id='gf_32' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_32' id='gform_32'  action='\/blogs\/greyform\/index.php\/wp-json\/wp\/v2\/pages\/333#gf_32' novalidate>\n                        <div class='gform_body gform-body'><ul id='gform_fields_32' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_32_26\" class=\"gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\" ><!--<p>\nFor your convenience, we offer two easy methods to refer your patient.\n<br \/><br \/>\nClick <a href=\"http:\/\/www.uabmedicine.org\/documents\/204604\/232170\/Ordering+for+Diagnostic+Imaging+-+UAB+Medicine\/41363658-4b3b-4b61-8b0d-11c9f306cf3a\">here<\/a> to download a printable form, which may be completed, signed, and faxed back to us, or simply complete and submit the electronic form below. -->To arrange an appointment, please contact the access team via the number below. <br \/><br \/>\n\nUAB Medicine Imaging Appointments: <a tel:2058018750>205.801.8750<\/a>\n<\/p><\/li><li id=\"field_32_1\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Patients Legal  Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_32_1'>\n                            \n                            <span id='input_32_1_3_container' class='name_first' >\n                                                    <input type='text' name='input_1.3' id='input_32_1_3' value='' aria-label='First name'   aria-required='true'     \/>\n                                                    <label for='input_32_1_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_32_1_6_container' class='name_last' >\n                                                    <input type='text' name='input_1.6' id='input_32_1_6' value='' aria-label='Last name'   aria-required='true'     \/>\n                                                    <label for='input_32_1_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_32_47\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Preferred name (if different from Legal name)<\/label><div class='ginput_complex ginput_container has_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name' id='input_32_47'>\n                            <span id='input_32_47_2_container' class='name_prefix name_prefix_select' >\n                                                    <select name='input_47.2' id='input_32_47_2' aria-label='Name prefix'    aria-required='false'   >\n                          <option value=''><\/option><option value='Dr.' >Dr.<\/option><option value='Miss' >Miss<\/option><option value='Mr.' >Mr.<\/option><option value='Mrs.' >Mrs.<\/option><option value='Ms.' >Ms.<\/option><option value='Prof.' >Prof.<\/option><option value='Rev.' >Rev.<\/option>\n                      <\/select>\n                                                    <label for='input_32_47_2' >Prefix<\/label>\n                                                  <\/span>\n                            <span id='input_32_47_3_container' class='name_first' >\n                                                    <input type='text' name='input_47.3' id='input_32_47_3' value='' aria-label='First name'   aria-required='false'     \/>\n                                                    <label for='input_32_47_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_32_47_6_container' class='name_last' >\n                                                    <input type='text' name='input_47.6' id='input_32_47_6' value='' aria-label='Last name'   aria-required='false'     \/>\n                                                    <label for='input_32_47_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_32_30\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_32_30' >Select a preference<\/label><div class='ginput_container ginput_container_select'><select name='input_30' id='input_32_30' class='large gfield_select'     aria-invalid=\"false\" ><option value='' ><\/option><option value='He\/Him\/His' >He\/Him\/His<\/option><option value='She\/Her\/Hers' >She\/Her\/Hers<\/option><option value='They\/Them\/Their' >They\/Them\/Their<\/option><\/select><\/div><\/li><li id=\"field_32_2\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Patient Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div id='input_32_2' class='ginput_container ginput_complex'><div class=\"clear-multi\"><div class='gfield_date_dropdown_month ginput_container ginput_container_date' id='input_32_2_1_container'><select name='input_2[]' id='input_32_2_1'   aria-required='true'   aria-label='Month'><option value=''>Month<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_day ginput_container ginput_container_date' id='input_32_2_2_container'><select name='input_2[]' id='input_32_2_2'   aria-required='true'   aria-label='Day'><option value=''>Day<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date' id='input_32_2_3_container'><select name='input_2[]' id='input_32_2_3'   aria-required='true'   aria-label='Year'><option value=''>Year<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/div><\/li><li id=\"field_32_3\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_32_3' >Patient Phone Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_3' id='input_32_3' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_32_4\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_32_4' >Patient Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_4' id='input_32_4' type='email' value='' class='medium'   placeholder='ex: name@example.com' aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_32_5\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_32_5' >Reason for Exam<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_5' id='input_32_5' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_32_6\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_32_6' >Signs and Symptoms<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_32_6' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_32_7\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_32_7' >ICD-10 Code<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_32_7' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_32_8\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_32_8' >CPT Code<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_32_8' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_32_9\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_32_9' >Insurance Information (Group\/Claim#)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_32_9' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_32_10\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_32_10' >Pre Cert\/Auth#<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_32_10' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_32_28\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_32_28' >Effective Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_28' id='input_32_28' type='text' value='' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_32_28_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_32_28_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_32_28' class='gform_hidden' value='https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_32_11\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_32_11' >Expiration Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_11' id='input_32_11' type='text' value='' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_32_11_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_32_11_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_32_11' class='gform_hidden' value='https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_32_12\" class=\"gfield gf_list_3col gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Diagnostic Imaging<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_32_12'><li class='gchoice gchoice_32_12_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.1' type='checkbox'  value='Radiology (Xray)'  id='choice_32_12_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_32_12_1' id='label_32_12_1'>Radiology (Xray)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_32_12_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.2' type='checkbox'  value='Fluoroscope (GI)'  id='choice_32_12_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_32_12_2' id='label_32_12_2'>Fluoroscope (GI)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_32_12_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.3' type='checkbox'  value='Mammography'  id='choice_32_12_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_32_12_3' id='label_32_12_3'>Mammography<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_32_12_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.4' type='checkbox'  value='CT'  id='choice_32_12_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_32_12_4' id='label_32_12_4'>CT<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_32_12_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.5' type='checkbox'  value='Ultrasound'  id='choice_32_12_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_32_12_5' id='label_32_12_5'>Ultrasound<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_32_12_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.6' type='checkbox'  value='Angiography'  id='choice_32_12_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_32_12_6' id='label_32_12_6'>Angiography<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_32_12_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.7' type='checkbox'  value='Bone Density (DEXA) (*For a Nuclear Medicine bone scan please call 975-8326)'  id='choice_32_12_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_32_12_7' id='label_32_12_7'>Bone Density (DEXA) (*For a Nuclear Medicine bone scan please call 975-8326)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_32_12_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.8' type='checkbox'  value='MRI'  id='choice_32_12_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_32_12_8' id='label_32_12_8'>MRI<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_32_12_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.9' type='checkbox'  value='Other'  id='choice_32_12_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_32_12_9' id='label_32_12_9'>Other<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_32_44\" class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\" ><h5 style=\"color: #cc0000;\"><b>PLEASE SELECT A DIAGNOSTIC IMAGING LOCATION<\/b><\/h5><\/li><li id=\"field_32_31\" class=\"gfield gfield--width-full gf_left_third field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >UAB Medicine Leeds<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_32_31'>\n\t\t\t<li class='gchoice gchoice_32_31_0'>\n\t\t\t\t<input name='input_31' type='radio' value='Leeds Location'  id='choice_32_31_0'    \/>\n\t\t\t\t<label for='choice_32_31_0' id='label_32_31_0'>Select this location<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_32_33\" class=\"gfield gfield--width-full gf_middle_third field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Gardendale Primary &amp; Specialty Care<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_32_33'>\n\t\t\t<li class='gchoice gchoice_32_33_0'>\n\t\t\t\t<input name='input_33' type='radio' value='Gardendale Primary Specialty location'  id='choice_32_33_0'    \/>\n\t\t\t\t<label for='choice_32_33_0' id='label_32_33_0'>Select this location<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_32_35\" class=\"gfield gfield--width-full gf_right_third field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >The Kirklin Clinic of UAB Hospital<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_32_35'>\n\t\t\t<li class='gchoice gchoice_32_35_0'>\n\t\t\t\t<input name='input_35' type='radio' value='TKC Location'  id='choice_32_35_0'    \/>\n\t\t\t\t<label for='choice_32_35_0' id='label_32_35_0'>Select this location<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_32_32\" class=\"gfield gfield--width-full gf_left_third gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\" ><p><b>UAB Medicine Leeds<\/b><br\/>\n1141 Payton Way<br\/>\nLeeds, AL 35094<br\/>\nHours: 8 am-5 pm<br\/>\nMonday through Friday<br\/>\n<ul>Imaging services offered:\n<li> X-ray<\/li>\n<li>Mammogram<\/li>\n<li>Ultrasound<\/li>\n<li>MRI<\/li>\n<li>CT scans<\/li>\n<\/ul>\n<\/p><\/li><li id=\"field_32_34\" class=\"gfield gfield--width-full gf_middle_third gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\" ><p><b>Gardendale Primary & Specialty Care<\/b><br\/>\n960 Rocket Way<br\/>\nGardendale, AL 35071<br\/>\nHours: 8 am-5 pm<br\/>\nMonday through Friday<br\/>\n<ul>Imaging services offered:\n<li> X-ray<\/li>\n<li>Mammogram<\/li>\n<li>Ultrasound<\/li>\n<li>MRI<\/li>\n<li>CT scans<\/li>\n<\/ul>\n<\/p><\/li><li id=\"field_32_36\" class=\"gfield gfield--width-full gf_right_third gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\" ><p><b>The Kirklin Clinic of UAB Hospital<\/b><br\/>\n2000 6th Ave. South<br\/>\nBirmingham, AL 35233<br\/>\nHours: 7 am-7 pm<br\/>\nMonday through Friday<br\/>\n<ul>Imaging services offered:\n<li>MRI<\/li>\n<li>CT scans<\/li>\n<li>Ultrasound<\/li>\n<li>Diagnostic radiology<\/li>\n<li>Gastrointestinal (GI) radiology<\/li>\n<li>Screening and diagnostic\nmammograms & procedures<\/li>\n<\/ul>\n<\/p><\/li><li id=\"field_32_37\" class=\"gfield gfield--width-full gf_left_third field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Hoover Primary &amp; Specialty Care<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_32_37'>\n\t\t\t<li class='gchoice gchoice_32_37_0'>\n\t\t\t\t<input name='input_37' type='radio' value='Hoover Primary Specialty location'  id='choice_32_37_0'    \/>\n\t\t\t\t<label for='choice_32_37_0' id='label_32_37_0'>Select this location<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_32_39\" class=\"gfield gfield--width-full gf_middle_third field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >UAB Hospital-Highlands<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_32_39'>\n\t\t\t<li class='gchoice gchoice_32_39_0'>\n\t\t\t\t<input name='input_39' type='radio' value='UAB Highlands location'  id='choice_32_39_0'    \/>\n\t\t\t\t<label for='choice_32_39_0' id='label_32_39_0'>Select this location<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_32_46\" class=\"gfield gfield--width-full gf_right_third field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >First Available. No Prefererence<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_32_46'>\n\t\t\t<li class='gchoice gchoice_32_46_0'>\n\t\t\t\t<input name='input_46' type='radio' value='Select this option'  id='choice_32_46_0'    \/>\n\t\t\t\t<label for='choice_32_46_0' id='label_32_46_0'>Select this option<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_32_38\" class=\"gfield gfield--width-full gf_left_third gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\" ><p><b>Hoover Primary & Specialty Care<\/b><br\/>\n501 Emery Drive West<br\/>\nHoover, AL 35244<br\/>\nHours: 8 am-5 pm<br\/>\nMonday through Friday<br\/>\n<ul>Imaging services offered:\n<li>X-ray<\/li>\n<li>Mammogram<\/li>\n<li>Ultrasound<\/li>\n<\/ul>\n<\/p><\/li><li id=\"field_32_40\" class=\"gfield gfield--width-full gf_middle_third gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\" ><p><b>UAB Hospital-Highlands<\/b><\/br\/>\n1201 11th Ave. South<br\/>\nBirmingham, AL 35205<br\/>\nHours: 7 am-5 pm<br\/>\nMonday through Friday<br\/>\n<ul>Imaging services offered:\n<li>MRI<\/li>\n<li>CT Scans<\/li>\n<li>Ultrasound<\/li>\n<li>Diagnostic Radiology<\/li>\n<\/ul>\n<\/p><\/li><li id=\"field_32_42\" class=\"gfield gfield--width-full gf_right_third gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\" ><p>If you do not have a location preference or want first available, select this option<\/p><\/li><li id=\"field_32_13\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_32_13' >Other<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_32_13' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_32_14\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_32_14' >Area(s) to be Imaged<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_32_14' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_32_15\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_32_15' >Biopsy or Aspiration<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_32_15' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_32_16\" class=\"gfield gf_list_2col gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Iodinated Contrast<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_32_16'>\n\t\t\t<li class='gchoice gchoice_32_16_0'>\n\t\t\t\t<input name='input_16' type='radio' value='Without'  id='choice_32_16_0'    \/>\n\t\t\t\t<label for='choice_32_16_0' id='label_32_16_0'>Without<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_32_16_1'>\n\t\t\t\t<input name='input_16' type='radio' value='With'  id='choice_32_16_1'    \/>\n\t\t\t\t<label for='choice_32_16_1' id='label_32_16_1'>With<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_32_16_2'>\n\t\t\t\t<input name='input_16' type='radio' value='With and Without'  id='choice_32_16_2'    \/>\n\t\t\t\t<label for='choice_32_16_2' id='label_32_16_2'>With and Without<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_32_17\" class=\"gfield gf_list_2col gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Gadolinium Contrast<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_32_17'>\n\t\t\t<li class='gchoice gchoice_32_17_0'>\n\t\t\t\t<input name='input_17' type='radio' value='Without'  id='choice_32_17_0'    \/>\n\t\t\t\t<label for='choice_32_17_0' id='label_32_17_0'>Without<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_32_17_1'>\n\t\t\t\t<input name='input_17' type='radio' value='With'  id='choice_32_17_1'    \/>\n\t\t\t\t<label for='choice_32_17_1' id='label_32_17_1'>With<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_32_17_2'>\n\t\t\t\t<input name='input_17' type='radio' value='With and Without'  id='choice_32_17_2'    \/>\n\t\t\t\t<label for='choice_32_17_2' id='label_32_17_2'>With and Without<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_32_17_3'>\n\t\t\t\t<input name='input_17' type='radio' value='Discretion of Radiologist'  id='choice_32_17_3'    \/>\n\t\t\t\t<label for='choice_32_17_3' id='label_32_17_3'>Discretion of Radiologist<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_32_18\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_32_18' >Creatine (value, date, if available)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_32_18' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_32_19\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_32_19' >Allergies<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_19' id='input_32_19' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_32_20\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_32_20' >Physician Name\/NPI #<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_32_20' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_32_21\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_32_21' >Clinic Contact<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_32_21' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_32_22\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" 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